Briefing Paper: Infant and Early Childhood Mental Health and Early Intervention (Part C): Policies and practices for supporting the social and emotional development and mental health of infants and toddlers in the context of parent-child relationships

The Importance of Early Relationships

Adverse Childhood Experiences and Toxic Stress

Trauma-Informed Care

Resilience

Developmental Delay, Disability, and Parenting

Families who have a young child with a developmental delay or disability may experience a variety of stressors. These stressors may include social isolation, social stigma, feelings of guilt, worry about the ability of their child to make friends, worry about the ability of their child to live an independent life, and a loss of parental career and social opportunities. It is important for early intervention practitioners to be sensitive to these stressors and the emotional experience of parents, while understanding that this will differ across families.

Certain diagnoses, such as autism spectrum disorder (ASD), can cause parental stress and may challenge parent-child attachment. A meta-analysis of the impact of parenting stress found a significant difference between the stress of parents of children with ASD, as well as children diagnosed with other disabilities, compared to parents of typically developing children (Hayes & Watson, 2013).

Additionally, parents with a child in the Newborn/Neonatal Intensive Care Unit (NICU) may themselves experience post-traumatic stress (Schecter et al., 2019) that may affect the parent-child relationship (Beck, 2015), and they often experience postpartum depression.

Professionals can support parents of young children with a developmental delay or disability by listening to their story and following the family's lead on the use of words to describe how they see their child's and family's situation. Some parents may benefit from counseling.

"Counseling ought to empower parents using the dialogue that they articulate rather than reflecting the practitioners' assumptions about what they imagine it to be like, based on the tragic concept of disabilities."

Early intervention teams must be sensitive to the potential stress and challenges experienced by parents of children with developmental delays or disabilities, as well as their need for support. Families can benefit from connecting with other families who have had similar experiences through a referral to a Parent Training and Information Center. Some families with significant stress or emotional challenges may also benefit from family counseling.

Early Intervention (Part C) Foundations

Early intervention, in accordance with the Individuals with Disabilities Education Act (IDEA) Part C, provides services for infants and toddlers, from birth to age three with and at-risk for developmental delays and disabilities, and their families.

State early intervention (Part C) programs are located within different state lead agencies, including education, health, social services, developmental disabilities and increasingly within early childhood agencies, along with other early learning and care programs for children birth to age 5 and their families that consolidates or creates a new agency to promote early childhood governance as outlined in the Build Initiative's A Framework for Choosing a State-Level Early Childhood Governance System.

A System Framework for Building High-Quality Early Intervention and Preschool Special Education Programs supports states to address "What does a state need to put into place to encourage/support/require local implementation of evidence-based practices that result in positive outcomes for young children with disabilities and their families?". The framework includes quality indicators within six system components (see Figure 2).

Figure 2. Early Intervention (Part C) System Framework

The federal IDEA Part C statute and IDEA Regulations establish the requirements for the provision of early intervention and the rights of families under the IDEA Part C. State early intervention (Part C) programs develop State Part C Regulations and Policies, procedures and guidance that includes state's eligibility criteria, evaluation and assessment requirements, and personnel qualifications.

This briefing paper addresses how states may examine their policies and procedures in these areas to effectively address the social-emotional, developmental, and mental health needs of eligible infants and toddlers and provide evidence-based services to support parent-child relationships.

Early intervention services support parents and other caregivers to promote the child's development within daily activities and routines (natural environments). Increasingly early intervention practitioners use a coaching approach. How states provide early intervention is addressed in the Seven Key Principles and Practices for Providing Early Intervention Services in Natural Environments that were developed by a national workgroup (see Figure 3). State early intervention (Part C) programs may also provide training and support for the implementation of several research-based service delivery approaches or models.

Figure 3. Early Intervention Key Principles and Practices

1. Infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts.
2. All families, with the necessary supports and resources, can enhance their children's learning and development.
3. The primary role of a service provider in early intervention is to work with and support family members and caregivers in children's lives.
4. The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child's and family members' preferences, learning styles and cultural beliefs.
5. IFSP outcomes must be functional and based on children's and families' needs and family-identified priorities.
6. The family's priorities, needs and interests are addressed most appropriately by a primary provider who represents and receives team and community support.
7. Interventions with young children and family members must be based on explicit principles, validated practices, best available research, and relevant laws and regulations.

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IECMH Foundations

Multidisciplinary early intervention (Part C) teams support and coach parents and other caregivers to promote a child's development within daily routines, activities, and places. IECMH practitioners utilize promotion, prevention, and treatment strategies to address the child's mental health and focus on the parent-child dyadic relationship.

Both early intervention (Part C) and IECMH systems can be seen as addressing the social-emotional development of infants and toddlers and as promoting the parent-child relationship. Figure 5 shows this intersection, which may be larger than illustrated.

Figure 5. Intersection between Early Intervention Part C and IECMH

• EI Part C
  • Support and coach parents to promote their child's development within daily routines
  • Multidisciplinary team approach
• IECMH
  • Promotion, prevention, treatment of mental health
  • Focus on the parent-child dyadic relationship
• Both
  • Social and emotional development
  • Parent-child relationship

Knowing that the social-emotional and mental health needs of infants and toddlers are supported through nurturing parent-child relationships, early intervention should use strategies that bolster the parent-child relationship and social-emotional capacities of the infant-toddler, which will promote growth in all areas of development.

Several state early intervention (Part C) programs have begun to promote IECMH policies and make available evidence-based IECMH services - either by early intervention teams or through collaboration and partnerships with other mental health organizations. We have spotlighted several states throughout this paper.

Social and emotional well-being and mental health are inclusive of one's unique identity, including racial identity. A child's identity and self-concept are actively developing in the first years of life. Therefore, the consideration of race, diversity, and equity must be foundational to policies and practices that address social-emotional development and mental health.

The field of early childhood has begun to intentionally acknowledge the impact of historical and structural racism and historical trauma on communities of color and the impact of the environment or society on infants and young children is sometimes overlooked (Berry et al., 2021).

However, studies have demonstrated that structural and interpersonal racism often leads to disparities in access to services and resources.

According to the Irving Harris Institute, diversity-informed practice strives for diversity, inclusion, and equity in teaching, training, research, writing, public policy and advocacy, and direct service. Their tenets include:

One effective strategy for ensuring an equitable system is the creation of infrastructure that integrates reflective questions and practice into each segment of the system, from policymakers to practitioners.

Reflective questions to be considered include:

• How are privilege and power shaping this?
• What assumptions are being made?
• Who is benefiting from this and how?
• Who is being further marginalized and how?
• What can we do to ensure that all families have access, equity, and justice?
• What role is race playing in this?
• How is race connected to power in this policy?
• How does this policy connect to the patterns of racism, historically and currently?
• How can this policy challenge or disrupt this pattern?

The Racial Equity Toolkit: An Opportunity to Operationalize Equity can be used by agencies and organizations to consider racial equity in policies, practices, programs, budgets, strategies, and actions that reduce racial inequities and promote success for all groups (Nelson & Brooks, 2015).

The concepts, practices, and strategies outlined in this briefing paper can and should be adapted with cultural responsiveness to best serve families of all races, ethnicity, languages, cultural backgrounds and ability, and different family structures.

Referrals of Children with Social and Emotional Delays

While state early intervention (Part C) programs are required under IDEA Regulations 34 CFR §303.302 and 34 CFR §303.303 to establish a comprehensive statewide child find system to identify, locate, and evaluate all infants and toddlers who may be eligible for services.

Based on the state's definition of developmental delay or disability, states may consider expanding strategies to specifically focus on identifying infants and toddlers with social-emotional delays.

Supporting Social-Emotional and Mental Health Needs of Young Children Through Part C Early Intervention: Results of a 50-state Survey found that 30 state early intervention (Part C) programs provide online and in-person training to referral sources that includes information about referring children with social-emotional concerns (Smith et al., 2020).

Early intervention practitioners may not have received specific training in social-emotional development or infant and early childhood mental health and therefore may not feel they are able to discuss the importance of referring young children where there is a concern in this area of development.

The referral of infants and toddlers with social-emotional concerns can be increased if state early intervention focus child find and outreach efforts to social service providers that address homelessness, domestic violence, teen parenting, substance abuse disorder, and adult mental health. As delays in social-emotional development may not be as obvious as those in other domains, state early intervention (Part C) programs can help health, early child and social service providers to be aware of social-emotional "red flags" and incorporate developmental screening that includes social-emotional development.

Outreach to birth hospitals, including newborn and pediatric intensive care units, can help identify parents who have experienced trauma related to their baby's premature birth, birth trauma, or other medical/birth complications.

For more information, see Michigan in Appendix A: State Spotlights.

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Referrals Related to the Child Abuse, Prevention and Treatment Act (CAPTA)

Reauthorization of both CAPTA in 2003, and IDEA in 2004 and subsequent IDEA Regulations 34 CFR §303.303 require states to establish procedures for the referral of children to early intervention (Part C) for screening or evaluation when abuse and neglect is substantiated by the child welfare agency.

The public policy effort to systematically refer young children who have experienced abuse and neglect or who were affected by substance use in utero can be seen as stemming from the publication of the seminal 2000 book From Neurons to Neighborhoods: the Science of Early Childhood Development, in which the authors state:

"Decades of research on the early development of the brain convey a powerful and sobering message about its susceptibility to harmful influences. This leads us to be deeply concerned about the well-being of young children who suffer from extreme deprivation, inadequate nutrition, neurotoxic exposures, or other insults that can cause significant (although sometimes subtle) brain damage during the prenatal or early childhood years...

...and early intervention efforts should be substantially expanded to reduce documented risks that arise from harmful prenatal and early postnatal neurotoxic exposures, as well as from seriously disrupted early relationships due to chronic mental health problems, substance abuse, and violence in families."

Subsequent research has shown that around 40% of young children in child welfare have a developmental or behavioral problem that would likely qualify them for early intervention services. However, only 13% of infants and toddlers received developmental or behavioral intervention (Stahmer et al., 2005).

IDEA Regulations 34 CFR §303.303 were amended to additionally require state early intervention (Part C) programs to develop policies and procedures for the referral of young children who are "Identified as affected by illegal substance abuse, or withdrawal symptoms resulting from prenatal drug exposure".

In Child Maltreatment 2019, the U.S. Department of Health & Human Services, Administration for Children and Families reported that 28 states and territories reported on the number of eligible children referred to early intervention (Part C) from child welfare and several of those cited low percentages in 2019 (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2021, p.81).

Five years after the passage of the amendments, a 2016 study showed that fewer than a fifth of all children with a substantiated case of abuse or neglect (18.2%) received a referral to early intervention Part C (Johnson-Motoyama et al., 2016) showing that there is much work to be done to ensure that all children are referred.

State early intervention (Part C) programs worked in collaboration with state child protection/child welfare agencies in the mid-2000s to develop CAPTA referral policies and procedures. These policies and procedures should be revisited to ensure they are effective and being followed. Data analysis and field interviews with early intervention and child welfare staff can be used to guide needed revisions to policies, procedures, and training to support timely and effective referrals, including effective screening and evaluations.

The Comprehensive Addiction and Recovery Act (CARA) of 2016 included changes to CAPTA, which require states to develop a Plan of Safe Care (POSC) for infants identified as affected by parental substance use disorder, showing withdrawal symptoms, or Fetal Alcohol Spectrum Disorders (FASD). The POSC is to ensure the safety and well-being of such infants following discharge from the hospital and addresses the health and treatment needs of the infants and affected family members or caregivers, as well as referral to early intervention Part C services and/or other early childhood services.

For more information, see Rhode Island in Appendix A: State Spotlights.

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Screening for Social and Emotional Development

Early intervention (Part C) programs may include developmental screening to identify developmental concerns in young children as part of their child find efforts, however they also promote collaboration with statewide community level efforts to offer developmental screening.

These wider developmental screening efforts include primary health care providers and early learning and care providers (e.g., home visitors, child care providers, Early Head Start) in helping to identify developmental concerns in infants and toddlers and making timely referrals to early intervention programs.

Research has shown that screening tools focused on social-emotional development are more effective than broad developmental screening tools for identifying children who need further evaluation of social-emotional concerns (Williams et al., 2017). Some referral sources (health, child care, Early Head Start, home visiting, etc.) increasingly use screening tools for social-emotional development, such as the Ages & Stages Questionnaires: Social-Emotional, Second Edition (ASQ:SE-2), which is likely to increase the number of referrals of children with possible social and emotional developmental challenges. A national survey conducted by the National Center for Children in Poverty in 2020 found that eight state early intervention (Part C) programs require the use of the ASQ:SE-2 and another 30 states recommend its use (Smith et al., 2020).

Procedures around screening differ from state-to-state when it comes to CAPTA referrals, with either child welfare or early intervention personnel conducting the screening, while other states conduct a full multidisciplinary developmental evaluation without requiring a screening. Only nine states "require the use of a social-emotional screening and/or evaluation tool for children involved in a substantiated case of abuse or neglect, although nearly half recommend a social-emotional tool" (Smith et al., 2020, p.7).

In Meeting the Social-Emotional Needs of Infants and Toddlers: Guidance for Early Intervention Program Providers and Other Early Childhood Professionals, the Clinical Clues of Social-Emotional Development Delays and Disabilities Chart include items and behaviors that were cross-referenced from a variety of social-emotional screening and assessment tools. These clinical triggers can alert non-mental health and mental health professionals alike that "the presence of these indicators strongly suggest that a social-emotional/mental health assessment may be indicated". The list of behaviors and items are clustered into concerns about sleep, eating, comfort, relating to people, mood, emotions and feelings, self-harm, behavior, possible exposure to excessive/toxic stress, and regression (New York State Department of Health Early Intervention Program, 2017, pp.31-33).

Figure 6 includes several tools for screening for social and emotional development.

For more information, see New York in Appendix A: State Spotlights.

Figure 6. Screening Tools for Social-Emotional Development

Tool	Age Range
Ages & Stages Questionnaire: Social-Emotional (ASQ:SE-2)	1–72 months
Greenspan Social-Emotional Growth Chart	0–42 months
Brief Infant and Toddler Social and Emotional Assessment (BITSEA)	12–36 months

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Postpartum Depression Screening

Perinatal or postpartum mood and anxiety disorder (PMAD) is associated with less responsive parenting and disruption of infant-parent-child interaction; however, it often goes unaddressed (Earls, 2010). Early intervention programs can play a role in either screening or referring a parent for screening for postpartum depression. Five state early intervention (Part C) programs screen for postpartum depression and 18 states reported that they refer mothers for evaluations or treatment of maternal depression to other health or mental health providers (Smith et al., 2020).

Early intervention teams should be aware of postpartum depression risk factors, including:

• depression or anxiety during pregnancy;
• stressful life events experienced during pregnancy or in the postpartum period;
• traumatic birth experience
• preterm birth/infant admission to neonatal intensive care (NICU);
• low levels of social support;
• previous history of depression; and
• breastfeeding problems.

The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a depression screening tool for postpartum depression and includes ten items and takes less than five minutes to complete (Lancaster et al., 2010).

As maternal depression can interfere with responsive parenting and contribute to problems in the parent-child relationship parent, early intervention (Part C) teams should help parents access an appropriate mental health provider based on the results of the screening that either they or another entity conducted.

Treatment services may include psychotherapy or counseling for mild-to-moderate peripartum depression and psychiatric pharmacologic treatment in moderate-to-severe cases of postpartum depression. There is also an increasing interest in screening fathers for perinatal depression (Walsh et al., 2020).

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Other Family Risk Factor Screening

Tools For Assessing Social and Emotional Development

Considerations For Including a Mental Health Professional As Part of the Evaluation Team

Adding a mental health professional (e.g., social worker, family counselor, psychologist) or someone trained and/or endorsed in infant mental health to the evaluation team can enhance the team's ability to assess social and emotional development.

This should be considered:

• when the referral of the child is made under CAPTA;
• when a screening tool has already identified social and emotional concerns; or
• where there are known family-related risk factors (such as substance use disorder, domestic violence, homelessness, abuse, or neglect).

A mental health professional may be accessed from a community mental health agency if not currently part of the early intervention team.

Determining whether to include a mental health professional on the evaluation team is similar to determining whether to include other disciplines (e.g., speech, motor, health) based on the referral and the presenting circumstances.

In 2020, 13 states reported that they include early intervention practitioners with training or expertise in infant-toddler mental health as part of eligibility evaluation teams and 11 states reported having written guidance regarding their participation. One state explained:

"A positive screen on the ASQ:SE-2 indicates that the evaluation team should consider including a professional with a background in infant-toddler early childhood mental health and social-emotional development."

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Use of the Diagnostic Classification DC:0-5

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5) is commonly used to classify mental health and developmental disorders in infants and young children.

DC:0-5 includes several disorders (e.g., neurodevelopmental disorders; sensory processing disorders; anxiety disorders; mood disorders; obsessive compulsive disorders and related disorders; sleep, eating, and crying disorders; trauma, stress, and depression disorders (including reactive attachment disorder; posttraumatic stress disorder; relationship disorders) that are related to IECMH and that have a high likelihood of leading to a delay in social-emotional development.

Trained mental health clinicians who work as part of an early intervention team or community mental health organizations can use DC:0-5 to:

• determine the extent and nature of the relationship disruption, psychosocial stressors, and trauma they observe to be leading to social-emotional and mental health issues for the young child;
• determine if the family could benefit from evidence-based IECMH dyadic or group treatment (either within early intervention or through a referral); and
• identify conditions that would make the child eligible under the state early intervention (Part C) diagnosed/established conditions list.

In 2020, 8 state early intervention (Part C) programs reported that they require or recommend the use of DC:0-5 (Smith et al., 2020). Some states, such as Colorado, require early intervention provider agencies to employ a DC:0-5-trained mental health clinician. DC:0-5 training targets clinicians from mental health, health, and early intervention who are responsible for assessment and diagnosis (Zeanah et al., 2017).

It is helpful for early intervention teams to have a working understanding of DC:0-5 as it is commonly used by mental health and child welfare systems that may serve infants, toddlers, and their families eligible for early intervention (Part C). DC:0-5 provides a common language to use across disciplines and programs for understanding parent-child relational disruptions and guiding potential interventions and treatments for the child and family.

For more information, see Colorado in Appendix A: State Spotlights.

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Other Assessment Tools Focused on the Parent-Child Relationship

State Early Intervention (Part C) Developmental Delay Criteria and Diagnosed Conditions

At-Risk Eligibility Category

Based on the information in this section, state early intervention (Part C) programs should consider the following strategies related to "referral, screening, assessment and eligibility" that can help ensure the participation of children with social-emotional and mental health concerns in early intervention:

1. Expand child find outreach efforts to the full range of providers and settings that serve children at-risk of social-emotional difficulties (e.g., social service organizations, domestic violence or homeless shelters).
2. Encourage other early learning and care providers (e.g., home visiting, child care, Early Head Start) and healthcare providers to screen for social and emotional development concerns. The American Academy of Pediatrics and Bright Futures Recommendations for Preventive Pediatric Health Care periodicity chart includes psychosocial and behavioral screening beginning at birth.
3. Partner with the child welfare agency to examine CAPTA and CARA Plans of Safe Care policies and procedures to ensure timely and effective referrals of children with potential social-emotional delay and mental health issues dues to maltreatment and/or parental abuse use in utero.
4. Promote use of screening tools that address social and emotional development.
5. Promote use of a tool focused on social and emotional development as part of the evaluation to supplement the multi-domain tool used.
6. Promote the inclusion of a licensed mental health specialist or professional trained and/or endorsed in IMH on the evaluation team when appropriate (e.g., CAPTA referrals, when there are social and emotional development concerns or family risk factors), who may either be a member of the early intervention team or accessed through a partnership with another agency.
7. Expand the list of diagnosed conditions for eligibility to include additional IECMH-related conditions including attachment disorder, posttraumatic stress, trauma, depressive and other mood disorders, eating, sleep, crying, and regulation disorders.
8. Partner with other organizations to provide training for mental health clinicians to help identify the presence of infant mental health conditions (e.g., DC:0-5) that can also help teams determine whether the child and family could benefit from a referral for evidence-based IECMH intervention or treatment.

Public Awareness and Universal Professional Development

IECMH preventive-intervention practices can be used by practitioners to support healthy parent-child relationships to prevent severe relationship and mental health issues, but also provide a foundation from which parents can nurture and promote their child's development across domains.

The following IECMH practices can be used by intervention providers from across disciplines, not just mental health professionals on the team. These practices can be incorporated into professional development either as distinct trainings or threaded into existing training modules (see the Workforce Development section later in this document).

Preventive-intervention approaches and their requirements for personnel qualifications and training/certification are presented in Figure 10.

Reflective Practice

Facilitating Attuned Interactions (FAN)

The Facilitating Attuned Interactions (FAN) approach, developed by Linda Gilkerson, PhD and colleagues with the Fussy Baby Network at the Erikson Institute, is both a conceptual model and a practical tool for family engagement and reflective practice.

The FAN approach helps practitioners:

1. improve their ability to read parents' cues and respond with interventions that match what parents need moment-to-moment;
2. recognize and regulate their own feelings when working with families to build their reflective capacity;
3. improve the relationship they have with harder-to-engage families; and
4. enhance their ability to provide attuned developmental information in a way that increases parental capacity.

For early intervention teams the FAN approach "may help increase collaboration with parents by shifting the mindset of the professional and facilitating more meaningful relationships with parents that enhance their child's ability to support their child's growth and development" (Cosgrove et al., 2019, p.254).

The FAN tool, shown in Figure 11, can help early intervention professionals read cues from parents and themselves and, thus, provide empathetic and appropriate responses.

For more information, see Wisconsin in Appendix A: State Spotlights.

Figure 11. Facilitating Attuned Interactions Tool (FAN)

Copyright © Gilkerson, 2016. Used with permission.

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IECMH Consultation

IECMH Consultation (IECMHC) is a preventive service used to improve children's social-emotional development and behavioral health (ZERO TO THREE, 2017). According to The Center of Excellence for Infant and Early Childhood Mental Health, the aim of IECMH consultation is to build adults' capacity to strengthen and support the healthy social and emotional development of children.

IECMHC is rooted in relationship-based practice that recognizes the importance of strong, positive relationships between the practitioner and parents/caregivers to support effective caregiving practices that promote young children's development. Consultation is individualized to address the immediate needs of a child, family, and program taking into consideration cultural, language, and organizational contexts.

While IECMHC has helped early childhood educators meet the social, emotional, and mental health needs of young children in classroom settings, more recently it has expanded into other settings such as primary care, child welfare, home visiting programs, and early intervention.

IECMH consultants, in collaboration with the early intervention practitioner, explore strategies to address the mental health needs of children, families, and staff. They can also help the team determine when a referral for IECMH treatment is recommended to help restore or create a healthy and nurturing parent-child attachment relationship, often earlier and before a child exhibits more extreme issues that require more intensive intervention or treatment.

For more information, see Alabama in Appendix A: State Spotlights.

In addition to working with individual early intervention practitioners and teams, IECMH consultants can also help local early intervention programs build the capacity of their early intervention personnel to support the social, emotional, and mental health needs of the children, families, and staff. General topics and/or themes include working with families that have many challenges, working with resistance, understanding parental depression, etc. IECMH consultants can provide "programmatic" consultation for administrators, such as to consider the impact policies and procedures may have on family engagement, relationships among staff and families, etc. (Center of Excellence for Infant and Early Childhood Mental Health, 2020).

IECMH consultants may work for early intervention programs as staff, contractors, or for a local or regional organization that provides IECMH consultation to home visiting, child care, Pre-K, Head Start or Early Head Start as part of collaborative efforts.

For more information, see Illinois in Appendix A: State Spotlights.

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Pyramid Model for Promoting Social and Emotional Competence in Infants and Young Children

The Pyramid Model for Promoting Social Emotional Competence in Infants and Young Children promotes social-emotional development, supporting children in experiencing responsive relationships with caregivers, developing relationships, exploring and learning within environments, communicating in play, and expressing and regulating emotions.

The Pyramid Model's tiered promotion-prevention-intervention approach includes universal practices to promote social-emotional development, secondary prevention practices to address the needs of children with social-emotional delays, and intensive individualized interventions for children with persistent challenging behavior — all supported by an effective workforce (see Figure 12).

The Pyramid Model framework is used within early intervention services, infant-toddler care environments, family child care homes, early childhood programs, Head Start, and public early childhood education programs. The National Center for Pyramid Model Innovations (NCPMI) provides materials, resources, and technical assistance for using the Pyramid Model in Part C early intervention programs.

Figure 12. Pyramid Model Tiers

NCPMI promotes the following primary principles for using the Pyramid Model with infants and toddlers and their families in early intervention (Part C):

1. Support practitioners in building collaborative partnerships with all families.
2. Use family coaching strategies to meet the needs of all caregivers.
3. Provide families with knowledge and skills related to responsive caregiving and nurturing and responsive relationships.
4. Build families' confidence and competence in supporting their child's social-emotional development.
5. Provide families with tools and strategies that address and focus on the prevention of challenging behavior.

NCPMI provides resources for the program-wide implementation of Pyramid Model practices in early intervention Part C. These materials include:

• Roadmap to Effective Intervention Practices: Statewide Implementation of the Pyramid Model and State Leadership Team Benchmarks of Quality: Implementing the Pyramid Model Statewide — materials state teams use to guide widespread implementation of the Pyramid Model;
• Pyramid Model Training for early intervention service professionals;
• Pyramid Model Early Intervention (Part C) Benchmarks of Quality: fidelity tool program or agency leadership teams use to guide implementation of critical elements of the approach;
• Early Interventionist Pyramid Practices Fidelity Instrument (EIPPFI) — fidelity tool early interventionists and coaches use to assess practice strengths and identify areas for growth. Practice domains of the EIPPFI are:
  1. building partnerships with families;
  2. social-emotional development;
  3. family-centered coaching;
  4. dyadic relationships;
  5. supporting families with children with severe, persistent challenging behavior; and
  6. social-emotional assessment.
• early intervention practitioner coaching materials (e.g., coaching guidance, strategies, and log); and
• early interventionist practice implementation materials (e.g., practice checklist, caregiver practices, family-centered coaching strategies).

NCPMI includes resources that address the relationship between the Pyramid Model and Early Childhood Mental Health Consultation and include a Crosswalk of Infant Early Childhood Mental Health Consultation and Pyramid Model Coaching. These resources examine how partnerships with IECMH consultants can support Pyramid Model implementation through consultation to the program leadership team, consultation to practitioners, and guiding the provision of supports and services to children and their families.

They also examine how IECMH consultants can bring additional expertise to the Pyramid Model framework, for example:

• considering trauma-informed care;
• attachment to caregivers;
• supporting staff and families experiencing depression or adversity; and
• working with families where members with substance use disorder.

For more information, see Nevada in Appendix A: State Spotlights.

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NEAR@Home

IECMH treatment can help infants and young children and their families for whom the parent-child relationship has been significantly disrupted.

According to the Handbook of Infant Mental Health, there have been "dramatic advances in the knowledge base of infant mental health... perhaps none is as striking as the growing evidence base about effective interventions" (Zeanah, 2019, p.481).

Extreme disruption includes experiences of trauma, such as abuse or neglect of the child or siblings, interpersonal/domestic violence, mental health or substance use disorder affecting parenting ability, etc.

Disruption can also happen when parents' own experience of childhood trauma affects their ability to parent or when parents struggle to accept having a child with a disability. Referral for IECMH treatment may also include children with a diagnosed mental health disorder.

The early intervention team in collaboration with an IECMH consultant or mental health professional can determine whether a referral for IECMH treatment is recommended.

Parenting Programs

Dyadic Treatment and Therapy

Dyadic treatment/therapy aims to increase sensitive, responsive parenting, a healthy parent-child relationship, and positive child behavior and development.

In dyadic treatment, a clinician works with the infant or young child and parent together, partnering with the parent to notice the child's cues and to respond in ways that promote a strong, nurturing parent-child relationship through enjoyable interactions.

Some models address issues related to attachment, separation, trauma, and unresolved grief and loss as they affect the care of the infant or toddler.

The National Center for Children in Poverty (NCCP)'s PRiSM page on Dyadic Treatment describes several models that have shown evidence of effectiveness in treating social-emotional, mental health, and behavioral problems in young children. These evidence-based treatment therapies involve rigorous training and certification for clinicians and may have qualification, licensure, or endorsement requirements.

In 2020, 24 state early intervention (Part C) programs reported providing dyadic treatment to eligible infants and toddlers and their families according to the NCCP's 50 state survey with six states requiring and another six states recommending the use of particular evidence-based models (Smith et al., 2020).

Several states are engaged in efforts to train clinicians in evidence-based dyadic treatment to expand the number of children and parents who can have access to this treatment. Other states may refer families to other community organizations or licensed mental health clinicians for dyadic treatment.

Figure 15 presents dyadic therapies applicable for children birth to three and their parents, according to PRiSM, that are considered either evidence-based practices (EBPs) or promising practices (PPs).

For more information, see Georgia in Appendix A: State Spotlights.

Figure 15. Dyadic Treatments and Therapies

Evidence-Based Practices (EBPs)

• Child-Parent Psychotherapy (CPP) is for children from birth to five years who have experienced trauma or are at-risk of insecure attachment or social-emotional problems. Randomized controlled trials have shown significant improvements in children's mood, challenging behaviors; trauma symptoms and biological stress response (cortisol) and improvements in parent's mood, stress, trauma symptoms and parental relationship, as well as improvements in parent-child relationship quality.
• Parent-Child Interaction Therapy (PCIT) involves observation and coaching of parent-child interactions to address challenging behavior for children from two to seven years. Several studies have examined PCIT effectiveness that conclude that this dyadic treatment reduces child behavior and parent stress and improves parent-child interactions among children with behavior scores in the clinical range.
• Attachment and Biobehavioral Catch-up (ABC) is a 10-week in-home program to help parents provide nurturing care to children from 6 to 24 months old who have experienced early adversity. ABC providers coach parents and other caregivers during in-person sessions in practices that help children develop attachment, self-regulation, and coping skills. A systematic review of randomized control trials of ABC conducted with populations of children involved in child welfare or foster care found that the program had positive impacts across several child outcomes, including fewer problem behaviors, and greater positive attachment.

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Promising Practices (PPs)

• Parent-Child Care (PC-CARE) is a six-week dyadic treatment program for children ages 1-10 and their parents or caregivers who have experienced trauma. With fewer sessions than traditional therapy models, it has been found to improve children's behavior, improve parenting, and reduce parenting stress.
• Infant Mental Health Home Visiting (IMH HV) is a dyadic treatment model in which licensed mental health professionals provide infant-parent psychotherapy, developmental guidance, emotional support, etc., using a home-based approach. IMH HV has been in use in Michigan for more than 40 years with an evaluation underway to assess the impact.

Based on the information provided in this section, we believe state early intervention (Part C) systems should consider increasing access to IECMH services and practices, as follows:

1. Promote a focus on the importance of the social and emotional development and mental health of infants and toddlers within the context of relationships through a collaborative public awareness campaign.
2. Promote a basic understanding of IECMH and prevention and intervention practices that support healthy social and emotional development and parent-child relationships through professional development and guidance materials for early intervention practitioners, supervisors, and administrators.
3. Support implementation of preventive-intervention models/approaches (e.g., reflective practice, FAN Approach; Pyramid Model; NEAR@Home) utilizing implementation science strategies (e.g., professional development, coaching and supporting leadership).
4. Develop a system of IECMH consultation to support early intervention practitioners in identifying and better meeting the social-emotional needs of eligible infants and toddlers with mental health needs and supporting the parent-child relationship. This may be accomplished in collaboration with other early learning and care or mental health agencies or organizations.
5. Encourage relationships at the local level between early intervention (Part C) and local mental health professionals and organizations, such as community mental health agencies, local early childhood coalitions/groups, and associations of infant mental health to facilitate coordination of services.
6. Support access to evidence-based dyadic treatment when the parent-child relationship has been negatively affected by trauma or other family stressors. Clinicians trained in these approaches may be a part of early intervention teams or accessed through another program/organization.
7. Support access to evidence-based parenting programs that focus on positive parent-child relationships and parenting skills to promote the child's social-emotional growth.
8. Encourage early intervention teams to help adult family members access needed mental health, including supports (e.g., screening, evaluation, and treatment for mental health needs including post-partum depression, substance use disorder, and access to needed domestic violence support) that present challenges to the parent-child relationship.

Personnel competencies or standards describe the knowledge, skills, and disposition of a professional discipline. Personnel competencies or standards differ from state licensing or certification issued by state or national agencies to individuals who meet specific requirements, such as graduation from an accredited Institution of Higher Education (IHE) program, or passing a national examination.

As such, they guide state certification and licensing requirements for each specific professional discipline and guide curriculum development for IHE professional preparation programs and in-service professional development (Bruder et al., 2019).

Some state early intervention (Part C) programs have developed specific early intervention competencies as part of certification for developmental specialists (special educators) and to guide professional development. These state competencies may be based on or include:

• The Division of Early Childhood (DEC) has both Initial Practice-Based Standards for Early Interventionists/Early Childhood Special Educators and Recommended Practices for early intervention that support young children's access and participation in inclusive settings and natural environments and address cultural and linguistic diversity.
• Early Childhood Personnel Center (ECPC), an Office of Special Education Programs (OSEP) funded project that has developed Cross-Disciplinary Competencies for early intervention that incorporate family-centered practices that "support families in their caregiving role of [with] their child".
• The ZERO TO THREE Competencies for Prenatal to Age 5 (P-5) include specific evidence-based teaching methods and practices that support and nurture young children's social-emotional, cognitive, and language and literacy development and learning.

State competency systems may include using Practice-Based Coaching to support the acquisition of competencies of key practices and to promote the fidelity of evidence-based practices. This may include observation of the practice being performed, either in-person or a recording of the early intervention visit together with structured coaching sessions.

Specific IMH competencies were first developed by the Michigan Association for Infant Mental Health (MI-AIMH). The Michigan Department of Education (MDE), the lead agency for early intervention (Part C), recognized that "infant mental health is a specialization within the early intervention field" and supported a cross-disciplinary group of experts to develop competencies that were approved by the MI-AIMH board in 1997 (Michigan Association for Infant Mental Health, 2017, p.5). The IMH competencies are built on those identified in the MI-AIMH Training Guidelines (1986) along with the TASK Documents published by ZERO TO THREE in 1990, and early intervention competencies developed by the MDE in 1996.

The eight competency areas have been further refined over the years to include:

1. theoretical foundations;
2. law, regulation, and agency policy;
3. systems expertise;
4. direct service skills;
5. working with others;
6. communicating;
7. thinking; and
8. reflection.

These IMH competencies apply to all infant and family-serving disciplines, sectors, and scopes of practice. Because they are based on competencies created specifically for early intervention, they can be particularly helpful for the early intervention Part C workforce. They provide a framework for individuals and systems to identify existing areas of competence (e.g., infant development, disorders of infancy, family-centered practice, screening and assessment) and areas where additional training may be required (e.g., relationship-based practice, attachment, trauma, grief, and loss).

The Alliance for the Advancement of Infant Mental Health licenses the use of the Competency Guidelines and/or Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant & Early Childhood Mental Health to state associations of infant mental health (AIMHs) that have been established in 33 states.

Some states, such as California, have developed their own competencies. The California Center for Infant-Family and Early Childhood Mental Health produced a California Compendium of Training Guidelines, Personnel Competencies, and Professional Endorsement Criteria for Infant-Family and Early Childhood Mental Health, which ties personnel competencies to endorsement and training for professionals working with young children and their families across the continuum of infant-family and early childhood mental health.

The Center of Excellence for Infant and Early Childhood Mental Health Consultation Competencies describe "building a national consensus on the knowledge and the array of foundational skills and abilities needed to become a competent IECMH consultant".

State early intervention (Part C) programs may consider incorporating IECMH competencies into their competencies or personnel standards.

For more information, see North Carolina in Appendix A: State Spotlights.

IDEA Regulations 34 CFR §303.118 require state early intervention programs to establish and maintain a Comprehensive System of Personnel Development (CSPD) that includes the training of early intervention personnel, promoting the higher education preparation of students to enter the early intervention field, and establish requirements for qualified personnel in 34 CFR §303.31.

Several state early intervention (Part C) programs partner and fund universities or other organizations to provide in-service training and other professional development. Some states tie training requirements to certification of early intervention practitioners, with some states requiring continuing education to maintain a practitioner's certification.

State early intervention (Part C) programs should explore how to incorporate IECMH prevention and preventive-intervention practices into a variety of professional development opportunities for all early intervention practitioners. Additionally, states may also target specific professional development to mental health professionals, e.g., social workers, family therapists, and psychologists for evidence-based treatments.

Professional development for all early intervention personnel may include, but is not limited to:

• the science of early relationships for healthy social emotional development for infants and toddlers (for example, Introduction to Attachment Theory);
• reflective and relationship-based practices;
• trauma-informed care to address ACEs (Adverse Childhood Experiences);
• Reflective Supervision/Consultation (RS/C) inclusive of supervisors and administrators, in addition to practitioners who will receive RS/C;
• how to write functional IFSP outcomes and strategies that address the social and emotional needs of children and family outcomes and may include IECMH treatment;
• training and ongoing opportunities for processing and discussing racial equity, building self-awareness (for example, through RS/C); and
• learning about local community agencies or resources that are available as supports to families when additional IECMH services are needed.

Training on particular models or approaches can also be offered to early intervention practitioners, including:

• The Pyramid Model Consortium's Pyramid Model Practices;
• Center of Excellence for Infant and Early Childhood Mental Health's IECMH Consultation;
• Erikson Institute's Facilitating Attuned Interactions Approach (FAN); and
• Start Early's NEAR@Home.

Training on treatment-level IECMH models and approaches may also be offered to mental health clinicians in collaboration with other early childhood agencies and organizations, such as state children's mental health agencies, local community mental health agencies, and associations of IMH (if operating in their state). Specialized training in evidence-based dyadic treatment can be conducted collaboratively across state agencies and even across states.

States may consider establishing Communities of Practice to support practitioners interested in using IECMH practices within early intervention (Part C). At the national level the Division of Early Childhood (DEC) has established an Infant Mental Health Community of Practice to build the capacity of early intervention professionals around IECMH topics, increase knowledge of IECMH topics within local communities (including parents), support Institutes of Higher Education to provide courses and/or certification related to IECMH, increase awareness of and advocate for IECMH within local/state agencies, and explore funding opportunities for IECMH activities.

For more information, see Georgia in Appendix A: State Spotlights.

Endorsement is a credential that recognizes experiences that lead to competency. It does not replace licensure or certification but is meant as evidence of a specialization in IECMH. Endorsement can be cross-sector and multidisciplinary, recognizing a professional from any of several professional backgrounds (e.g., counseling early childhood and special education, nursing, pediatrics, psychiatry, psychology, social work) who have "completed specialized education, work, in-service training, and reflective supervision/consultation experiences that have led to competency in the promotion and/or practice of infant mental health" (Michigan Association for Infant Mental Health, 2017).

The Alliance for the Advancement of Infant Mental Health includes four Pathways to Early Childhood Mental Health Endorsement that are issued by state associations of IMH to professionals who are working with young children and families that apply.

These pathways include the specific work, education, in-service training, and reflective supervision/consultation requirements as well as the competencies for each of the four roles shown in Figure 16.

The National Center for Children in Poverty (NCCP) national survey of early intervention (Part C) states found that some states are working with their state's AIMH to offer training and IECMH endorsement to early intervention providers (Smith et al., 2020).

State early intervention (Part C) programs can support and encourage early intervention practitioners and particularly mental health clinicians to pursue IMH endorsement, if available through their state association of IMH or where states have their own IMH endorsement system (e.g., California, Illinois).

Reflective supervision has been characterized as a "relationship for learning" (Heller & Gilkerson, 2009, p.7) and "the process of examining, with someone else, the thoughts, feelings, actions, and reactions evoked in the course of working closely with infants, young children and their families" (Eggbeer et al., 2007, p.5).

Others have written that reflective supervision, "When it's going well... is a holding environment, a place to feel secure enough to expose insecurities, mistakes, questions and differences" (Fenichel, 1992, p.37), and "A safe, trusting reflective supervisory relationship, trusting reflective supervisory relationship develops most optimally with opportunity for regularly scheduled meetings between supervisor and supervisee(s) at a consistent time that is mutually agreed on, in a place that is comfortable, protected, and free from distractions or interruptions" (Weatherston & Eidson, 2019).

The term Reflective Supervision/Consultation (RS/C) is used to recognize that reflective support may come from a supervisor or a consultant from outside the agency. Regular and ongoing RS/C can be conducted with individual practitioners and with groups.

In an earlier section of this paper, we addressed reflective practice as a key strategy for early intervention practitioners to use to examine their thoughts, feelings and behaviors in their ongoing work with infants, toddlers and their families. RS/C provides an ongoing, regularly scheduled, and safe environment to do that reflection and provides support to the practitioner and can lead to professional growth and improve practice.

The University of Minnesota Center for Early Education and Development (CEED) identifies the key elements of reflective supervision as:

CEED studied the impact of reflective supervision with a cross-disciplinary group of early childhood professionals who received monthly group reflective supervision which led to the development of the "4Rs" Model:

The unique space created during reflective supervision provides the opportunity to pose and discuss questions related to racial equity and implicit bias, as highlighted in the initial section of this paper. Keys to meaningful engagement in reflective supervision and to deepen one's reflective capacity include building trust, emotional regulation, curiosity, bravery, self-awareness, and vulnerability. These skills also help one examine one's own implicit biases, which can deepen reflection and lead to personal and systematic action and change.

Based on the information provided in this section regarding IECMH workforce development we believe state early intervention (Part C) programs should consider the following opportunities, which may be addressed through collaborative partnerships with other organizations/agencies:

1. Incorporate IECMH topics into training modules for all early intervention practitioners, supervisors and administrators, including ACEs, toxic stress and the critical importance of early relationships for healthy social-emotional development and mental health of young children.
2. Make training available to EI practitioners on preventive-intervention models/approaches (e.g., FAN Approach; Pyramid Model; NEAR@Home) and reflective practice.
3. Make training available to mental health clinicians on evidence-based parenting groups and dyadic treatments.
4. Incorporate IMH competencies into state early intervention competencies, where applicable.
5. Promote and encourage mental health professionals (e.g., counselors, social workers, psychologists) in early intervention to receive IECMH training and/or endorsement as Infant Mental Health Specialist (IMHS) category or Infant Mental Health Mentor-Clinical.
6. Promote and encourage some early intervention practitioners to become endorsed at the Infant Family Specialist (IFS) category.
7. Support the development of an infrastructure system of reflective supervision/consultation (RS/C) to allow all early intervention personnel to receive regular and ongoing reflective supervision.

The following early intervention services under the IDEA Regulations 34 CFR §303.13 can be seen as allowing for the provision of IECMH services:

• Family training, counseling, and home visits include counseling by social workers, psychologists, and other qualified personnel (e.g., family therapists) (34 CFR §303.13(b)(3) and 34 CFR §303.13(c)).
• Psychological services include obtaining, integrating, and interpreting information about child behavior and child and family conditions related to learning, mental health, and development, and also psychological counseling for children and parents and family counseling (34 CFR §303.13(b)(10)).
• Social work services include social or emotional developmental assessment of the infant or toddler within the family context and Providing individual and family-group counseling with parents and other family members, and appropriate social skill-building activities with the infant or toddler and parents (34 CFR §303.13(b)(13)).

34 CFR §303.13(d) clarifies that nothing prohibits the identification in the IFSP of another type of service as an early intervention service, provided that the service meets the criteria identified in 34 CFR §303.13(a).

Therefore, IECMH services can be provided as part of the IFSP if they are designed to meet the developmental needs of an infant or toddler with a disability and the needs of the family to assist appropriately in the infant's or toddler's development (34 CFR §303.13(a)(4)), and are selected in collaboration with the parents (34 CFR §303.13(a)(2)).

As state early intervention (Part C) programs currently fund family counseling, psychological and social work services that are included in the IFSP, they can be used to provide and fund IECMH services and approaches by qualified personnel.

IECMH services can be provided and funded by another organization/agency and aligned and coordinated with other early intervention services on an IFSP, with all practitioners working as a transdisciplinary team. For example, a family may attend a parenting group or receive dyadic therapy that is provided and funded by another community organization.

All state early intervention (Part C) programs use Medicaid funding. However, the extent to which Medicaid supports the full range of early intervention services for children enrolled in Medicaid and early intervention (Part C) varies by state in both policy and practice.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) emphasizes prevention and early detection within its broad treatment mandate and can be used to fund early intervention services regardless of where early intervention (Part C) services are detailed in the Medicaid state plan that each state is required to submit to the US Centers for Medicare & Medicaid Services (Mann et al., 2019).

Federal Medicaid pays between 50% and 78% of the cost of services based on the current Federal Medical Assistance Percentage (FMAP) with states responsible for the remaining or "match" (Kaiser Commission on Medicaid and the Uninsured, 2012; Kaiser Family Foundation, n.d.). It therefore makes sense for state early intervention (Part C) programs to maximize the early intervention services funded through Medicaid for children enrolled.

IECMH Coverage Under Medicaid

Statutory clarifications, federal guidance, and legal decisions against state Medicaid programs have reinforced the inclusion of mental health services under EPSDT (Burak & Rolfes-Haase, 2018). A growing number of states have taken steps to add, identify, or clarify reimbursement for IECMH services (Smith et al., 2020).

Some states use Medicaid to pay for at least some mental health services in early intervention. A finance survey in 2018 found a majority of state early intervention (Part C) programs reported that their state used Medicaid to reimburse for family training/counseling (26 states), social work (25 states) and psychological services (29 states) (IDEA Infant & Toddler Coordinators Association, 2018).

Another survey by the National Center for Children in Poverty (NCCP 2018) on how states use Medicaid to cover IECMH services found that 35 states reported that Medicaid pays for an early childhood mental health specialist to provide services to address a child's mental health. The report found that 32 states use Medicaid to cover IECMH treatment (groups and dyadic treatment), with 15 states requiring the use of evidence-based tools or practices (Smith et al., 2018).

While IECMH intervention/treatment services can be funded by Medicaid, indirect services including IECMH consultation are less often funded through Medicaid since they are not tied to the individual service needs of a Medicaid-enrolled child. In 2018, 13 states reported that Medicaid funding is used for consultation with early childhood professionals and supports to address an individual child's behavioral and mental health needs (Smith et al., 2018). However, no states reported Medicaid funding for consultation with early childhood professionals and directors to help strengthen practices that promote young children's mental health and social-emotional growth.

A potential option for funding IECMH services under the Children's Health Insurance Program (CHIP) allows states to use up to 10% of CHIP funding to implement health services initiatives (HSIs). In 2019, 24 states had instituted an HSI through a state plan amendment, with six of these amendments being for behavioral health services (Medicaid and CHIP Payment and Access Commission, 2019).

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Medicaid Funding Structure and Methodology

State Medicaid agencies decide the funding structure and methodology, including fee-for-service, where the state directly reimburses providers for services provided, or through managed care organizations (MCOs), in which the state contracts with private health insurance plans with a capitated rate (set monthly/annual amount) per member.

Most children in the U.S. are served through MCO plans. However, some states have been able to "carve out" early intervention (and IDEA Part B special education and related services) from managed care to be funded on a fee-for-service basis and determine rates for reimbursement rather than being negotiated by the MCOs.

If billing under a fee-for-service basis, state early intervention (Part C) programs either use established service codes for each service, while other states developed a specific billing code for early intervention services (often with modifiers for location or method - group or individual) with all disciplines billing under that code. That code can be used to bill for IECMH work conducted by a qualified practitioner (licensed social worker, counselor, family therapist, or psychologist). Alternatively, services provided by those disciplines can be billed under their distinct service codes.

Medicaid claims require a diagnosis code that is typically from the ICD-10 (International Classification of Diseases 10th Revision) and DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). Often a broad development delay (unspecified) code can be used. As discussed in the eligibility section, there are crosswalks from DC:0-5 to ICD-10 and DSM-5 that clinicians can use for IECMH conditions. Some state Medicaid agencies have begun to recognize or recommend the use of age-appropriate diagnostic tools for mental health, notably the use of DC:0-5 instead of the DSM-5 used for school-aged children and adults (Burak & Rolfes-Haase, 2018). State early intervention (Part C) programs should check with their state Medicaid partners as to whether DC:0-5 can be entered as the diagnosis code for billing or whether it needs to crosswalk to the applicable ICD-10 or DSM-5 code.

Some states have also used Z codes (social, economic, and environmental determinants known to affect health and health-related outcomes) to bill Medicaid when a developmental delay or diagnosed medical condition is not present.

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Collaboration with Other Mental Health Agencies

State early intervention (Part C) programs may also collaborate closely with their state's children's mental health agency to ensure consistent processes and procedures for Medicaid services reimbursement for IECMH services.

Early intervention staff, along with their other mental health agency partners, can provide important expertise to state Medicaid officials on the social-emotional needs of young children and opportunities to prevent or mitigate more complex mental health challenges that can be more costly over time to encourage Medicaid funding of IECMH services.

While Medicaid is an important funding source for low-income families and children who may be eligible based on a disability diagnosis, states will also need to examine funding for IECMH services for other children and families, which may include private insurance, state IDEA Part C appropriations, and federal IDEA grant funds, which are seen as a payor of last resort.

For more information, see Hawaii in Appendix A: State Spotlights.

Provision of IECMH services (IECMH consultation, dyadic therapy, and parenting groups) or supports (Reflective Supervision/Consultation) may be achieved through partnerships and collaborations.

It may be possible for another agency or organization to provide and fund a service (e.g., dyadic therapy may be funded through the state's child's mental health agency or parenting group funded through the child welfare agency, with additional slots funded by Part C).

Several states have convened collaborative IECMH initiatives/workgroups to explore and plan how states can provide a continuum of promotion, preventive-intervention, and treatment services for young children and their families. IECMH collaboratives can address how to braid funding sources both for services as well as how to jointly fund professional development opportunities across disciplines.

Institutionalizing partnerships and collaborations through an interagency agreement or memorandum of agreement/understanding can help ensure that the partnership continues regardless of leadership and agency changes. An interagency agreement can address shared funding and reduce duplication of efforts.

State early intervention (Part C) programs may also explore possible federal grants or philanthropic funding. Such grants rarely fund direct services but can be used to build IECMH infrastructure or systems.

This may include funding to study and make recommendations regarding state investments for IECMH services or funding for professional development to ensure that personnel are available to provide evidence-based services or funding for pilot programs, demonstration sites, and statewide systems building efforts.

Federal grants have included, for example, Linking Actions for Unmet Needs in Children's Health (Project LAUNCH) from the Substance Abuse and Mental Health Services Administration (SAMHSA) and early childhood infrastructure grants such as the Preschool Development Grant Birth through Five (PDG B-5) and the Race To the Top-Early Learning Challenge (RTT-ELC). The American Recovery Plan Act (ARPA) funds received by state early intervention (Part C) programs and other early childhood programs can also be used.

Based on the information provided in this section, the following opportunities exist for state early intervention (Part C) systems about IECMH funding, partnership, and collaboration:

1. Examine state policies, standards, regulations, service definitions, codes, and rates to determine the ability to bill for IECMH services as part of the IFSP.
2. Meet with state Medicaid partners to examine Medicaid funding of IECMH services, including the use of applicable diagnosis codes.
3. Collaborate with the state mental health and/or IECMH leaders to explore how IECMH services can be made available to families eligible for early intervention (Part C).
4. Join or convene an IECMH collaborative workgroup with other agencies/organizations to explore braiding funding for IECMH services, professional development, and effective IECMH systems building.
5. Explore federal or philanthropic funding opportunities for IECMH systems building, professional development, etc.

State early intervention (Part C) programs can and should collaborate and partner with other agencies and organizations to implement IECMH policies and practices.

Potential Partners

Cross Agency and Program IECMH Initiatives

State early intervention (Part C) programs may consider the following to garner support for prioritizing efforts and expenditures to promote IECMH policies and practices:

Interagency Coordinating Council (ICC)

Meet with the state ICC to discuss and examine their support for a focused initiative around IECMH. Consider making a joint presentation with a state IECMH champion on the fundamentals of IECMH and its relevance to early intervention (Part C) and identify and discuss steps that the state early intervention program may take to promote IECMH. If the ICC has a subcommittee on effective services and practices, work with that committee before presenting to the full ICC. ICC endorsement for a focus on IECMH can help the early intervention (Part C) program allocate funding and human resources to institute IECMH policies and support the implementation of IECMH practices and services.

Strategic Plan

If the state early intervention (Part C) program has a strategic plan, promoting IECMH policies and practices can be incorporated into that plan with goals and strategies to be achieved over one to five years.

State Systematic Improvement Plan (SSIP)

Several states' SSIPs focus on evidence-based practices to improve social and emotional outcomes for children in early intervention (Part C). States may consider implementing evidence-based IECMH services that are highlighted in this paper to address the social and emotional development of infants and toddlers in the context of relationships with parents and other caregivers.

Self-Assessment

The IECMH and Early Intervention (Part C) Planning Tool (see Appendix B) can be used to examine IECMH policies and practices to address and prioritize. A self-assessment can help state early intervention (Part C) programs review their policies and practices against those outlined in this briefing paper, including eligibility and assessment, services and practices, workforce and professional development, and funding policies.

Given the many competing priorities and accountability requirements that state early intervention (Part C) programs must address, they may consider the following next steps:

Immediate Opportunities

Determine if there are any "easy wins" that can be achieved with relatively little effort, for example, current training modules or future modules can be revised to include IECMH, IECMH specialists can provide the keynote at a conference or host a focused webinar, and guidance can be provided on topics such as the use of social-emotional screening or assessment tools without changes to state regulations or policies.

Assign an IECMH Leader or Champion

Explore whether a staff person at the state early intervention (Part C) program has an interest or passion regarding IECMH issues and support them to take a lead as a champion of IECMH efforts. This person can build connections with key agencies and organizations and potentially play an active role in the state's association for IMH. For state early intervention (Part C) programs where the lead agency staff is very small, an alternative could be to look for a champion from an organization the state contracts with for professional development (e.g., through a university or other organization). A final option could be for the state early intervention (Part C) program to develop a contract with someone to lead the IECMH initiative.

Raise Awareness of IECMH through Professional Development

Raise awareness of IECMH through professional development Consider hosting, or cohosting with partners, IECMH professional development events for early intervention (Part C) leaders and practitioners such as a keynote and/or workshop at a state conference, hosting a webinar or webinar series on IECMH that can be recorded and made available asynchronously, and promoting training on IECMH offered by partner organizations.

For more information, see Connecticut in Appendix A: State Spotlights.

As state early intervention (Part C) programs consider beginning or furthering statewide efforts to promote IECMH policies and practices they should consider resources that address the effective implementation of evidence-based practices.

ECTA Center identifies the stages, steps, and activities that research has shown to help put evidence-based practices into widespread use:

The guide goes on to describe the stages of effective implementation as circular and dynamic, not linear, and often occur simultaneously. These implementation stages include:

1. Exploration: establish a leadership team, convene stakeholders, explore feasibility, secure agency/cross agency leadership support;
2. Installation: develop a communication plan, establish implementation sites and teams, develop system supports and infrastructure changes, address data, evaluation, and monitoring, build training and TA, finalize the plan;
3. Initial implementation: train and coach implementation site personnel, monitor practices, use improvement cycles and adjust organizational supports, evaluate fidelity and emerging outcomes;
4. Full Implementation: integrate data systems, policies and procedures, and funding, use performance assessment with implantation teams, use feedback and data to sustain fidelity; and
5. Continuous Program Improvement: select new sites and provide supports and begin the implementation process, establish mechanisms for sustaining fidelity of practices.

In implementing a statewide IECMH initiative, state early intervention (Part C) should consider the data and measurement implications.

This can include examining whether their current data system can collect information needed to generate reports that help them analyze the status and evaluate change over time. Data may include:

• Referrals — including the type of organization making the referral;
• Eligibility — including children with social and emotional developmental delay or mental health related diagnosed conditions;
• IFSP service and service provision — including family training and counseling, psychological services, and social work;
• IFSP Outcomes — related to social-emotional development and enhanced parent-child relationships and parenting;
• Workforce — Including qualified mental health professionals (social workers, psychologists, and family therapists), training modules/workshops attended, IMH endorsement, and RS/C provision; and
• Outcomes — social and emotional child outcomes measurement.

Analysis of these data can help state early intervention (Part C) programs examine the status of serving children with social and emotional delays, address any gaps, and evaluate change over time.

Recognizing that IECMH services may be provided to eligible children and families by other programs and organizations, state early intervention (Part C) programs may want to examine whether their data system can capture and report utilization regarding those services.

Considering the data that will be needed for an evaluation is an important step at the beginning of a new initiative or any new investment of funds and effort, and enables states to address equity issues regarding access to quality services.

In 2014, Alabama's system of Infant and Early Childhood Mental Health started with a federally funded Linking Actions for Unmet Needs in Children's Health (Project LAUNCH). The grant included hiring and training a cadre of IECMH consultants statewide, a reflective supervision lead, and staff. Alabama also funded an IECMH state coordinator position within the Department of Early Childhood Education to address policy development and systems building.

The IECMH state coordinator works closely with the Alabama Department of Mental Health - Infant and Early Childhood Mental Health Services director to build the IECMH system.

Alabama is piloting IECMH consultation with two EI provider agencies that includes:

• Tier 1: universal support, which is not child-specific and includes training for EI staff on the use of the Temperament and Atypical Behavior Scale (TABS);
• Tier 2: where EI practitioners bring cases to a team meeting for consultation; and
• Tier 3: where IECMH consultation is added under "psychological services" on the IFSP and includes consultation with the parent(s) and other team members.

The IECMH consultants can also facilitate referrals for dyadic treatment - with more than 35 clinicians trained in Child-Parent Psychotherapy (CPP) statewide.

A training module on social-emotional development and IECMH, was developed for early intervention practitioners that includes a focus on trauma-informed care, attachment, and other relevant topics. Alabama uses American Recovery Plan Act (ARPA) funds to support participation of contracted early intervention staff (therapists) who otherwise might not be able to attend the training. Alabama is also training clinicians in DC:0-5 to help them determine the need for dyadic therapy and to support the ability to bill Medicaid.

In the mid-2000s, the Office of Behavioral Health piloted placing early childhood mental health consultants in community-based mental health centers in two Colorado counties.

This program was later moved to the newly formed Office of Early Childhood (OEC) where it expanded across the state and grew from 17 full time equivalent (FTE) positions to 34 FTE. Utilizing one-time stimulus funds, the Early Childhood Mental Health (ECMH) Consultation program was able to grow to 52 FTE. Consultation in Colorado is also funded by philanthropic and private partners, with grants from the Buell Foundation adding roughly 17 FTE to this program.

In 2020, House Bill 20-1053 codified the ECMH Consultation Program into law, requiring the OEC to establish a model of consultation with a competency and qualification structure, as well as a professional development plan for all consultants across the state.

The OEC is working with leaders in Health Care Policy & Financing (HCPF) to explore whether Medicaid funding is a sustainable and reasonable approach to supporting ECMH consultation services.

ECMH consultants are licensed mental health providers with early childhood and developmental backgrounds and are all trained in DC:0-5. These consultants often refer children to early intervention (Part C) for further evaluation and act as a resource for EI teams by providing information and guidance; however, they do not complete Part C evaluations, nor do they provide direct intervention services.

Early Intervention Colorado (Part C) requires that local EI agencies have social emotional providers on their teams when needed, who are from a variety of professional disciplines including: infant mental health specialists, behavior analysts, family therapists, counselors, social workers, psychologists, psychiatrists, and infant family specialists. Social emotional providers who conduct evaluations of social-emotional development are required to complete DC:0-5 training.

In 2013, the State of Connecticut passed Public Act 13-178: An Act Concerning the Mental, Emotional and Behavioral Health of Youths which required the Birth to Three Program (early intervention IDEA Part C) to "provide mental health services to any child eligible for early intervention services" as needed and "Any child not eligible for services under said act shall be referred by the program to a licensed mental health care provider for evaluation and treatment, as needed".

However, Birth To Three had already focused on supporting mental health of infants and toddlers in the context of their families. That included the publication of the Service Guideline 4: Infant Mental Health: Assessment and intervention guidance for service providers and families of young children (2009) that was developed collaboratively with the Connecticut Association for Infant Mental Health (CT-AIMH) and was a revision to a document developed in 1998.

The legislation put a focus on IECMH and led to changes regarding screening and evaluation. This also led to an increase in CAPTA referrals and establishing regular training to the child welfare agency staff regarding the referral process to Birth to Three.

The Connecticut Birth To Three System requires that a mental health clinician be on the evaluation team if the referral was made due to concerns regarding social-emotional development. Additionally, if the child does not meet eligibility based on use of a multi-domain tool, the mental health clinician administers the Devereaux Early Childhood Assessment: Infant and Toddler (DECA-I/T).

In 2019, the Georgia House of Representatives formed a study committee, chaired by Representative Katie Dempsey, to examine Infant and Early Childhood Mental Health (IECMH). The study committee resulted in a report and a series of recommendations, including funding of an IECMH director position at the Georgia Department of Early Care and Learning (DECAL), a request for clarification on Medicaid billing codes for IECMH services, and investment in the IECMH workforce.

The work of the study committee also resulted in the Georgia Early Education Alliance for Ready Students (GEEARS) and the Georgia Department of Public Health (DPH) recognizing the need for additional social-emotional support for children in Georgia's Early Intervention program, Babies Can't Wait (BCW). DPH identified Child-Parent Psychotherapy (CPP) as a potential treatment that could benefit the children served in BCW.

GEEARS and DPH reached out to partners in Alabama and South Carolina to determine interest in jointly funded CPP training for clinicians across the three states. Alabama, having a history of investment in IECMH, offered slots in a CPP training event to clinicians in Georgia and South Carolina, thereby creating a regional CPP training cohort.

DECAL recognized that child care and Head Start would also benefit from CPP-trained clinicians and partnered with DPH and GEEARS to provide CPP training. DECAL and DPH planned to invest additional funds from the Preschool Development Grant Birth through Five (PDG B-5) and American Rescue Plan Act (ARPA) funds for the training of roughly 90 additional clinicians in Georgia.

Hawaii's Early Intervention Section (Part C) participated in a collaborative effort that was supported by the state Early Learning Board (the governing entity of the Executive Office on Early Learning) to develop a behavioral health action plan that would complement and augment existing plans, including the Early Childhood State Plan.

A cross-sector team and WestEd conducted a scan of the status of infant and early childhood mental health (IECMH) in Hawaii and conducted key informant interviews that resulted in Hawai'i's Integrated Infant and Early Childhood Behavioral Health Plan.

The plan proposes to integrate child and family mental health and trauma-informed care into health and early care and learning systems throughout Hawaii.

The plan includes goals and strategies to address the following components:

1. systems and policy;
2. marketing, outreach, and community education;
3. workforce development and consultation; and
4. programs and services.

Hawaii's collaborative IECMH effort has been financially and structurally supported by the Hawaii Community Foundation, the Early Childhood Action Strategy, and the State Department of Health. Foundations have also supported subsequent collaborative efforts to address funding for IECMH services and supports. Hawaii's Early Intervention Section (Part C) participated in this effort that resulted in the 2021 report Advancing Infant and Early Childhood Behavioral Health in Hawai'i: Exploring Options for Financing Sustainability, which examines sustainable funding for IECMH services, including information on diagnosis coding and billing, as well as potential funding sources.

A collaboration of philanthropic groups also supported an intensive nine-month-long trauma-informed Promising Minds Community of Practice (COP). The COP included a mixed group of early childhood professionals including early intervention, home visiting, child care, Early Head Start/Head Start, and family child interaction learning programs who reported that they gained knowledge and understanding of the impact of trauma on children, families and themselves and the importance of self-care, which proved to be very helpful during the COVID-19 pandemic.

In 2016, Illinois created the Illinois Action Plan to Integrate Early Childhood Mental Health into Child- and Family-Serving Systems, Prenatal through Age Five to integrate IECMH into child-serving systems and has made strides expanding and evaluating Illinois Model of Infant/Early Childhood Mental Health Consultation (IECMHC) across the state.

The Illinois early intervention program has addressed the social and emotional development of infants and toddler for more than 20 years, with a committee established in 1999 and a report published in 2002 that identified social-emotional development as the primary unmet need of infants, toddlers, and families in early intervention.

The committee recommended having a social-emotional (SE) consultant within each of the 25 Child and Family Connections (CFC) offices (Illinois' system point of entry), training in relationship-based EI, reflective consultation for CFC leadership, reflective supervision for service coordinators, social-emotional screening at intake for all children, integrated assessment and intervention planning, regular case consultation, and a SE consultant network.

SE consultants must have a master's degree in child development, special education, psychology, social work, counseling or a related field, along with supervised clinical experience with children and families, and knowledge of and training in typical and atypical infant development, attachment theory, family systems theory, psychopathology in infancy and toddlerhood, diagnosis of mental health disorders in infancy (DC:0-5), impact of stress and trauma in infancy, assessment of parent/child relationship, intervention to support parent/child relationship, and assessment of adult mental health disorders.

Funded through a grant to each CFC, the SE consultants provide professional development, clinical consultation, and systems support for infusing relationship-based, reflective practice throughout the EI process. Primary responsibilities of the SE consultant also include reflective consultation to the CFC leadership, individual and group case consultation, and the coordination of SE screening and specialized assessment, with a social worker, counselor, or psychologist joining the assessment/evaluation team when screening results indicate a need.

Illinois' credentialing process for psychological and other counseling service providers, such as licensed psychologists, professional counselors, family therapists, and clinical social workers, can provide clinical dyadic therapy. Additionally, Illinois Early Intervention Training Program staff who participate in Training of Trainers to help build the capacity of early intervention/early childhood educators in the state.

Several SE consultants have also participated in training on DC:0-5. Recognizing the importance of support for young children with social-emotional challenges in early intervention, the Illinois Bureau of Early Intervention recently included diagnoses from DC:0-5 in the list of medical diagnoses that make children eligible for early intervention services.

In 2019, The Nevada Early Intervention Services (Part C) program initiated statewide implementation of the Pyramid Model. Nevada was supported by NCPMI using implementation science and a systems approach to move from initial installation to implementation and scale-up.

A state leadership team uses the State Leadership Team Benchmarks of Quality for Implementing the Pyramid Model Statewide to put implementation and scale-up activities in place and track their progress. Program implementation coaches provide training and technical assistance to state-operated early intervention service agencies and community programs.

Training addresses Pyramid Model practices including program-wide leadership teaming, practice-based coaching, and use of data tools. Each local program forms a leadership team to guide implementation and plan for staff readiness and buy-in, family engagement, staff capacity, interventions for children with persistent challenging behavior, and the monitoring of implementation and outcomes (e.g., using the Pyramid Model Early Intervention Benchmarks of Quality). The local leadership team decides how to provide ongoing practitioner coaching to help personnel develop proficiency to implement Pyramid Model practices. Practitioner coaches collaborate with early interventionists to identify strengths and areas for growth using the Early Interventionist Pyramid Practices Fidelity Instrument (EIPPFI) in collaboration. The leadership teams review data from the practitioner coach log and the EIPPFI to monitor implementation fidelity and make decisions related to ongoing professional development.

In 2017, the New York State Department of Health Early Intervention Program published Meeting the Social-Emotional Development Needs of Infants and Toddlers: Guidance for Early Intervention Program Providers and Other Early childhood Professionals.

This document was the culmination of a joint taskforce convened in 2013 from two Governor-appointed bodies: The Early Intervention Coordinating Council (EICC), and the Early Childhood Advisory Council (ECAC).

The guidance document has four objectives:

1. ensure that the general population of young children receive routine and ongoing screening of children's development, including social-emotional development;
2. identify children at-risk of experiencing a social-emotional delay or disability and ensure that their families receive the assistance they need from the wide array of early childhood programs and services;
3. improve the early identification of children who may already be experiencing developmental delays in social-emotional development; and
4. ensure that evaluations and assessments for all children in the EI program adequately address social-emotional development, and that service coordinators, evaluators, and providers who are delivering EI services understand the importance of and pay attention to this area of development.

An EICC workgroup was created to help promote, disseminate, and train professionals on the guidance document. The workgroup created a social-emotional development webpage targeted towards families, as well as an online e-learning training for providers that includes five modules that provide specific instructions for early intervention professionals to address the social-emotional development of the children and families they serve.

New York State Department of Health Early Intervention Program is also part of a Trauma-Informed Collaborative that includes members from 15 state agencies, and is focused on promoting trauma-informed care and addressing social-emotional development.

There has been a broad interest across North Carolina agencies in promoting IECMH. This has included investments by the Division of Public Health making Triple P — Positive Parenting Program available across the state, as well as joint investments making available Circle of Security.

In 2017, as part of its State Systematic Improvement Plan (SSIP), the North Carolina Infant-Toddler Program (Part C) conducted a survey of early intervention providers regarding perceived IECMH strengths, resources and needs. Several implementation teams were established to address the results of the survey.

One action taken was to integrate IECMH competencies into the personnel standards for the Infant-Toddler (Part C) program. Two additional areas of focus and investment were to promote a family coaching approach with support from Dathan Rush and M'Lisa Shelden, which helped establish a foundation for working with families from a more dyadic perspective.

Additionally, North Carolina further promoted the Pyramid Model, which was already in use by other early childhood programs in the state, and the Infant-Toddler (Part C) program became a part of the state Pyramid Model leadership team.

North Carolina is also supporting the ABC: Attachment Biobehavioral Catchup, which is a rigorous mental health intervention, but implementation doesn't have to be by a mental health clinician. North Carolina also invested in the ASQ:SE-2, enabling provider agencies statewide to be able to use it and 50 clinicians have been trained in the DC:0-5 and will be training at least another 25.

The Infant-Toddler program has taken a leadership role in bringing the Association for the Advancement of IMH competencies and endorsement process to North Carolina, using Preschool Development Grant Birth through Five (PDG B-5) funds, and they are encouraging early intervention practitioners to become endorsed.

The Michigan early intervention program, known as Early On, selected improving social emotional outcomes for infants, toddlers, and their families as the focus for their State Systemic Improvement Plan (SSIP). Initially, Early On Michigan selected four service areas as pilot sites to implement evidence-based practices and evaluate activities and is currently scaling up to implement them in one-third of the state. The evidence-based practices include:

1. training and use of the electronic Devereaux Early Childhood Assessment for Infants and Toddlers (eDECA-I/T) that is sensitive enough to pick up social emotional concerns that other evaluation tools may miss; and
2. Pyramid Model training (five modules) with coaching to support providers using the Pyramid Model.

Additionally, Early On Michigan decided to address messaging and improve awareness of the importance of social and emotional development. This included purchasing Social Emotional Developmental Wheels from Michigan Association for Infant Mental Health and ZERO TO THREE. Early intervention providers reported that this tool has made it easier to start having conversations with families about social-emotional development. A contract with the Michigan Department of Health & Human Services Mental Health (MDHHS) was also developed for a consultant to provide foundational training in areas such as temperament, attachment, typical and atypical development, nurturing environments, and social emotional milestones.

Early On Michigan determined that mental health providers can diagnose infant mental health conditions, that have been included in their list of physical and mental conditions that make a child eligible for early intervention (Part C). Additionally, Infant Mental Health Endorsement is promoted, encouraged, and included in the Early On Michigan's Personnel Standards.

Since putting in place policies and procedures in 2005 to meet the Child Abuse Protection and Treatment Act (CAPTA) mandate for referral of children and their families when there is a substantiated case of abuse or neglect, Rhode Island has conducted a Continuous Quality Improvement (CQI) effort to address effective implementation of this requirement over several years.

A child welfare subcommittee (of the state Interagency Coordinating Council) conducted CQI that included reviewing data on referrals made, developmental screening conducted, and children determined eligible for early intervention (IDEA Part C). Policy changes that were made include developing: a CAPTA liaison position; a child welfare standardized referral protocol; standardized form and feedback loop so that child welfare knows the status of referral; as well training for both early intervention and child welfare staff.

Rhode Island also established a process where, unless there is an established delay or disability, referrals from child welfare are made to a home visiting entity First Connections (which receives some EI Part C funding) to conduct development screening (including ASQ:SE-2) and route referrals to home visiting when there is no risk of developmental delay identified. Rhode Island has a Family Visiting Council that works to align policies across home visiting programs and early intervention. The focus on CAPTA referrals has led to the need for the inclusion of social workers/mental health professionals on evaluation teams and recognition of the need for more professional development around IECMH.

Rhode Island's CAPTA work was featured in the following journal article:

• Bernstein, H., et al. (2020). Chance elevator encounters and tenacious champions: Collaborative referrals between child welfare and Early intervention, ZERO TO THREE Journal 40(6), 21-32.

The Wisconsin Alliance for Infant Mental Health (WI-AIMH) in collaboration with the Wisconsin Child Welfare Professional Development System (WCWPDS) provides professional development across disciplines, including early intervention (Part C) practitioners, in training and coaching on the Facilitating Attuned Interactions (FAN) approach, as well as reflective supervision and IMH consultation.

Local Birth to 3 programs applied for competitive grants from the Wisconsin Birth to 3 Program (IDEA Part C) to pilot innovative practices that have a positive impact on the social and emotional development of the children they serve. Many awardees used some of their grant funds for professional development in social-emotional well-being, including training in the FAN Approach.

More than 100 providers attended the "Level 1" two-day interactive training and "Level 2" completion of reflection tools with supervisors who receive reflective coaching to support their teams for a period of six months.

Learners then participated in a third day of interactive training. After practitioners complete the training, they can participate in a Community of Practice (CoP) with others implementing the FAN Approach. These CoP sessions are offered one to two times per year to deepen knowledge and skills of practitioners in the field. The FAN Approach training is open to all early intervention disciplines and their supervisors. Mental health consultants are encouraged to attend with their team.

Training has also been provided in the Pyramid Model Parents Interacting With Infants and Toddlers (PIWI) module, as it is felt that the coaching process aligns with the approach of early intervention and provides additional skills and strategies for supporting the parent-child dyad with a focus on social emotional elements within that interaction.

WI-AIMH developed Reflective Supervision Learning Collaborative, an experiential opportunity for program supervisors to learn about, experience, and implement reflective supervision within their agencies. The training will occur over five days throughout the year, along with monthly small group reflective meetings facilitated by infant mental health consultants.

Additionally, as a part of supporting ongoing professional development, Wisconsin Birth to 3 Program provides annual scholarships for early intervention professionals to attend a year-long Infant, Early Childhood, and Family Mental Health Capstone Certificate Program at the University of Wisconsin. Nearly 100 fellows have gone through this Capstone Certification across the state.

• 1.1. Expand child find outreach efforts to the full range of providers and settings that serve children at-risk of social-emotional difficulties (e.g., social service organizations, domestic violence/homeless shelters).
• 1.2. Encourage other early learning and care providers (e.g., home visiting, child care, Early Head Start) and healthcare providers to screen for social and emotional development concerns.
• 1.3. Partner with the child welfare agency to examine CAPTA and CARA Plans of Safe Care policies and procedures to ensure timely and effective referrals of children with potential social-emotional delay and mental health issues dues to maltreatment and/or parental abuse use in utero.
• 1.4. Promote the use of screening tools that address social and emotional development.
• 1.5. Promote the use of a tool focused on social and emotional development as part of the evaluation to supplement the multi-domain tool used.
• 1.6. Promote the inclusion of a licensed mental health specialist or professional trained and/ or endorsed in IMH on the evaluation team when appropriate (e.g., CAPTA referrals, when there are social and emotional development concerns or family risk factors), who may either be a member of the early intervention team or accessed through a partnership with another community organization.
• 1.7. Expand the list of diagnosed conditions for eligibility to include additional IECMH-related conditions including attachment disorder, posttraumatic stress, trauma, depressive and other mood disorders, eating, sleep, crying, and regulation disorders.
• 1.8. Partner with other organizations to provide training for mental health clinicians to help identify the presence of infant mental health conditions (e.g., DC:0-5) that can also help teams determine whether the child and family could benefit from a referral for evidence-based IECMH intervention/treatment.

• 2.1. Promote a focus on the importance of the social and emotional development and mental health of infants and toddlers within the context of relationships through a collaborative public awareness campaign.
• 2.2. Promote a basic understanding of IECMH and prevention and intervention practices that support healthy social and emotional development and parent-child relationships through professional development and guidance materials for early intervention practitioners, supervisors, and administrators.
• 2.3. Support implementation of preventive-intervention models/approaches (e.g., reflective practice, FAN approach; Pyramid Model; NEAR@Home) utilizing "implementation science" strategies (e.g., professional development, coaching, and supporting leadership).
• 2.4. Develop a system of IECMH consultation to support early intervention practitioners in identifying and better meeting the social-emotional needs of eligible infants and toddlers with mental health needs and supporting the parent-child relationship. This may be accomplished in collaboration with other early learning and care or mental health agencies or organizations.
• 2.5. Encourage relationships at the local level between early intervention (Part C) and local mental health professionals and organizations, such as community mental health agencies, local early childhood coalitions/groups, and associations of infant mental health to facilitate coordination of services.
• 2.6. Support access to evidence-based dyadic treatment when the parent-child relationship has been negatively affected by trauma or other family stressors. Clinicians trained in these approaches may be a part of early intervention teams or accessed through another program/organization.
• 2.7. Support access to evidence-based parenting programs that focus on positive parent-child relationships and parenting skills to promote the child's social-emotional growth.
• 2.8. Encourage early intervention teams to help adult family members access needed mental health, including supports (e.g., screening/evaluation and treatment for mental health needs incl. post-partum depression, substance use disorder, and access to needed domestic violence support) that present challenges to the parent-child relationship.

• 3.1. Incorporate IECMH topics into training modules for all early intervention practitioners, supervisors, and administrators, including ACEs, toxic stress, and the critical importance of early relationships for healthy social-emotional development and mental health of young children.
• 3.2. Make available training to EI practitioners on preventive-intervention models/approaches (e.g., FAN approach; Pyramid Model; NEAR@Home) and reflective practice.
• 3.3. Make training available to mental health clinicians on evidence-based parenting groups and dyadic treatments.
• 3.4. Incorporate IMH competencies into the state early intervention competencies, where applicable.
• 3.5. Promote and encourage mental health professionals in early intervention to receive IECMH training and/or endorsement as Infant Mental Health Specialist (IMHS) category or Infant Mental Health Mentor-Clinical.
• 3.6. Promote and encourage some early intervention practitioners to become endorsed at the Infant Family Specialist (IFS) category.
• 3.7. Support the development of an infrastructure system of Reflective Supervision/Consultation (RS/C) to allow all early intervention personnel to receive regular and ongoing reflective supervision.

• 4.1. Examine state policy/standards/regulations, service definitions, codes, and rates to determine the ability to bill for IECMH services as part of the IFSP.
• 4.2. Meet with state Medicaid partners to examine Medicaid funding of IECMH services, including the use of applicable diagnosis codes.
• 4.3. Collaborate with the state mental health and/or IECMH leaders to explore how IECMH services can be made available to families eligible for early intervention (Part C).
• 4.4. Join or convene an IECMH collaborative workgroup with other agencies/organizations to explore braiding funding for IECMH services, professional development, and effective IECMH systems building.
• 4.5. Explore federal or philanthropic funding opportunities for IECMH systems building, professional development, etc.