1304.24

Child Mental Health

(a) Mental Health Services

INTRODUCTION TO 1304.24

Head Start embraces a vision of mental wellness. The objective of 45 CFR 1304.24 is to build collaborative relationships among children, families, staff, mental health professionals, and the larger community, in order to enhance awareness and understanding of mental wellness and the contribution that mental health information and services can make to the wellness of all children and families.

The Child Mental Health standards, 45 CFR 1304.24(a), cover working collaboratively with parents, securing the services of mental health professionals, and developing a regular schedule of on-site mental health consultations involving mental health professionals, program staff, and parents.

1304.24(a)(1)(i)

(a) Mental health services.

(1) Grantee and delegate agencies must work collaboratively with parents (see 45 CFR 1304.40(f) for issues related to parent education) by:

(i) Soliciting parental information, observations, and concerns about their child's mental health;

Rationale:

Anticipating and understanding a child's behavior and development helps parents and staff respond in a manner more likely to enhance the child's development. This rationale serves 1304.24(a)(1)(i)-(iv).

Related Information:

See 45 CFR 1304.51(g) for information on agency confidentiality policies. See 45 CFR 1304.40(b)(1)(ii) on accessing community mental health services for the family.

Guidance:

Staff communication with parents draws upon parents' knowledge of their child's development, and respects their parenting strengths, values, culture, and childrearing approach. Relevant information shared in the family partnership agreement process, or drawn from the child's records, is incorporated into discussions. Communication about a child's mental health can occur through formal and informal opportunities, such as during home visits, staff-parent conferences, or parent meetings. For many families, issues related to mental health are sensitive ones, and must be approached with care. When staff take time, however, to establish rapport and to build trusting relationships with parents, the parents may learn to feel more comfortable discussing issues related to mental health.

Discussions between parents and staff focus on a variety of topics, including:

• developmental and cognitive phases, and typical behaviors or concerns associated with each phase,
• the child's special interests, needs, and strengths,
• any changes in the child's behavior, mood, or physical appearance which may reflect recent experiences, and
• any information on health conditions that may influence the child's behavior.

The information drawn from these discussions is used to help individualize services for each child.

When appropriate, a mental health professional is consulted to discuss a particular concern with parents and staff.

Performance Standard

1304.24(a)(1)(ii)

(ii) Sharing staff observations of their child and discussing and anticipating with parents their child's behavior and development, including separation and attachment issues;

Related Information:

See 45 CFR 1304.21(b)(1) about the development of secure relationships, particularly 45 CFR 1304.21(b)(1)(i) as it relates to attachment issues.

Guidance:

Staff have many opportunities to exchange information with parents on child development and growth. In formal and informal settings, information on the following topics can be presented.

• The typical development of young children.
  Information provided to parents helps them understand some behaviors that they may view as problematic, such as attention seeking and saying “no,” as part of a temporary phase that plays a positive role in the child's development.
• The development of individual children.
  When parents and staff understand and respect each child's particular abilities and temperament, undue pressure on both parents and children can be avoided. For example, some children develop motor skills faster than their peers, while others are able to control strong feelings at an earlier age than most. Training and information can help parents and staff recognize when each child is ready to achieve a particular skill or needs special help.
• Supporting parenting in the first few months following a birth.
  This period may be a time of stress, as parents adjust to new roles and cope with challenges such as limited sleep. Enlisting a family member or finding someone who can assist new parents with the care of their new baby and with other household responsibilities can ease this transition.
• Recognizing and understanding behavior that is an expression of their child's response to a stressful situation.
  It is helpful to understand that sudden changes in a child's behavior may be the child's response to a stressful situation.
• Ways to assist parents in helping children deal with separation issues.
  To help the child during separation, encourage parents to spend time in the facility with their child; bring tangible reminders of home and family, such as a favorite toy or photos; assist the child to play out themes of separation and reunion; and reassure the child about his or her parents' return. Parents, too, may experience anxiety over separation from their children. Staff help parents with such separation anxiety by validating their feelings, and by encouraging parent participation in the program.
• Attachment issues.
  To facilitate secure relationships and attachments to adult caregivers, consistent care from a small number of adults is advised. Agencies arrange for the same teacher to remain with the infant or toddler for the longest possible time in the program.

Performance Standard

1304.24(a)(1)(iii)

(iii) Discussing and identifying with parents appropriate responses to their child's behaviors;

Related Information:

See 45 CFR 1304.21(a)(3)(i)(C) and (D) about setting clear limits and respecting others, and 45 CFR 1304.52(h)(1)(iv) on using positive methods of child guidance.

Guidance:

Staff and parents share positive approaches they employ to respond to a child's behavior. Staff responses to parent inquiries provide an opportunity to explore and to model alternative approaches and techniques.

The behaviors that adults demonstrate are those which will be internalized and emulated by children. Staff discuss with parents the fact that parenting, while most often a fulfilling experience, also can be difficult and stressful, and that a parent's response to stress, just like responses to other behaviors, will be imitated by children. Training and information about age-appropriate behaviors and varying individual temperaments helps parents and staff both to determine appropriate responses and to model those behaviors. For such reasons, the following should be kept in mind:

• Developmental changes.
  Healthy social and emotional development depends upon how children view themselves, as well as the extent to which they feel valued by others. When adults have realistic expectations about a child's behavior, they respond with a variety of interventions that set constructive limits and help children to achieve self discipline. Providing children opportunities to succeed lays the foundation for healthy development.
• Environment.
  Day-to-day warmth and responsiveness from staff and parents influences a child's ability to recognize and to act upon his or her feelings. A comfortable, safe, interactive environment increases a child's sense of competence and control.

Positive techniques of guidance.

Undesirable behaviors, while a normal part of growing up, should be discouraged or redirected. The following strategies reflect best practices for responding to inappropriate behaviors

• anticipation of and elimination of potential problems,
• redirecting a child away from a conflict or negative event to a more positive activity,
• offering the child choices among activities that are acceptable to parents,
• helping a child learn about the logical or natural consequences of their actions, and
• encouraging respect for the feelings and rights of others.

Positive techniques are more effective than competition, comparison, or criticism. Rather than attempting to “stop” a child's negative behavior, positive techniques help him or her to find and practice skills that will help now and in the future. It is for that reason that Head Start programs never use corporal punishment. Staff work with parents to help them understand the negative effects of corporal punishment on self-esteem, and to find alternatives in the home.

There are many differences of opinion about parenting, and there is no single “best way” to parent. It is important, however, that children receive consistent messages that are respectful of the child and of family values, customs, and traditions.

Performance Standard

1304.24(a)(1)(iv)

(iv) Discussing how to strengthen nurturing, supportive environments and relationships in the home and at the program;

Related Information:

See 45 CFR 1304.21, Education and Early Child Development, and, in particular, standards (a)(1)(iii), (a)(3)(i)(A), (a)(3)(i)(D), (b)(1)(ii), (b)(2)(i), (c)(1)(iv), and (c)(1)(v), for additional information on supportive environments and nurturing relationships.

Guidance:

When interacting with children, adults support the development of trust, self-esteem, and identity by expressing respect and affection toward the child and by demonstrating responsiveness to his or her experiences, ideas, and feelings. Examples of respectful and responsive behaviors, which depend upon the developmental level of the child, include:

• Smiling at the child;
• Quickly comforting an infant in distress; and
• Nodding at a toddler in need of reassurance.

Establishing a supportive environment also involves assisting children to become comfortable, relaxed, happy, and involved in play and other activities. Staff and parents help children deal with anger, sadness, and frustration by comforting them, identifying and reflecting on their feelings, and helping them to use words, instead of acts of anger, to solve problems and disputes.

Positive social behavior among children, such as cooperation, is fostered by adults through modeling, coaching, and encouraging, rather than through lecturing, criticism, and punishment.

Performance Standard

1304.24(a)(1)(v)

(v) Helping parents to better understand mental health issues; and

Rationale:

Better understanding of mental health issues increases the likelihood that parents value and use the mental health information and services available to them. This rationale serves 1304.24(a)(1)(v)-(vi).

Related Information:

See 45 CFR 1304.40(f)(4) on discussing mental health issues with parents.

Guidance:

Agencies take a variety of steps to understand mental health issues, by:

• Providing opportunities for parents to learn about and participate in mental wellness activities;
• Providing access to mental health professionals through ongoing parent activities;
• Working with parents to develop support groups; and
• Helping parents access community mental health resources.

Performance Standard

1304.24(a)(1)(vi)

(vi) Supporting parents' participation in any needed mental health interventions.

Related Information:

See 45 CFR 1304.40(f)(4)(iii) on parent involvement in planning and implementing any mental health interventions for their children.

Guidance:

There are many ways that staff support parent participation in mental health interventions. Some of these include:

• Finding opportunities for parents to learn about the mental health professional, such as at the orientation for parents and at a variety of meetings and events throughout the year;
• Assisting parents to break down barriers to services, including
  • attending an orientation meeting with the mental health provider,
  • locating the transportation or child care needed to participate in services, and
  • finding assistance to pay for interventions; and
• Discussing the importance of interventions for the mental health of the entire family. Communicate to families that staff members are available to discuss mental health issues and to provide parents with information about how the program protects the confidentiality of the information they may choose to share.

Performance Standard

1304.24(a)(2)

(2) Grantee and delegate agencies must secure the services of mental health professionals on a schedule of sufficient frequency to enable the timely and effective identification of and intervention in family and staff concerns about a child's mental health; and

Rationale:

When grantee and delegate agencies have an ongoing relationship with a mental health provider, or with a group of providers, they are better able to secure appropriate services in a regular and timely manner.

Related Information:

See 45 CFR 1304.41(a)(2)(ii) for information on community partnerships with mental health providers. See 45 CFR 1304.52(d)(4) for additional information on mental health staff qualifications.

Guidance:

Grantee and delegate agencies make arrangements for mental health professionals to be available to help the program. Mental health professionals represent a variety of disciplines, including, but not limited to:

• psychiatry,
• psychology,
• psychiatric nursing,
• marriage and family therapy,
• clinical social work,
• behavioral and developmental pediatrics, and
• mental health counseling.

Head Start agencies augment the services of mental health professionals with services from individuals with the backgrounds, skills, and interests that can support program goals for promoting mental health. By consulting with their mental health professionals, agencies can determine: which services may be provided only by licensed or certified mental health professionals; which activities may be provided under the supervision of such a mental health professional; and which activities do not require the direct supervision of the mental health professional, such as parent education groups.

Schedules need to be frequent enough to allow the mental health professional to become familiar with the needs of children requiring assistance, to provide information and consultation, and to help locate any needed treatment or service in a timely fashion.

Performance Standard

1304.24(a)(3)

(3) Mental health program services must include a regular schedule of on-site mental health consultation involving the mental health professional, program staff, and parents on how to:

Rationale:

Regularly scheduled mental health services help to ensure that day-to-day program practices promote mental health. This rationale serves 1304.24(a)(3) and 1304.24(a)(3)(i).

Guidance:

See 45 CFR 1304.24(a)(3)(i)-(iv) for guidance on implementing this standard.

Performance Standard

1304.24(a)(3)(i)

(i) Design and implement program practices responsive to the identified behavioral and mental health concerns of an individual child or group of children;

Related Information:

See 45 CFR 1304.20(b) on developmental screenings. See 45 CFR 1304.21(c)(2) about developing a program that supports individual children.

Guidance:

Through a combination of planned activities and spontaneous interventions, the mental health professional assists staff and parents to help children practice skills that foster mentally healthy development.

Regular meetings with appropriate staff and parents provide the mental health professional with opportunities to:

• Develop and implement training on how to assess the child's strengths and needs, and on how to plan developmentally appropriate activities that are based upon valid findings;
• Make curricula enhancements. For many topics, such as reducing stress, resolving conflicts, and coping with violence, the mental health professional can provide recommendations on appropriate resources;
• Make recommendations on resources related to mental health education that would be helpful to home visitors and appropriate for group socialization activities;
• Implement practices responsive to infants and toddlers and their rapidly changing needs; and
• Hold periodic conferences with parents and staff to share ideas for supporting children who have been identified as needing special help.

Performance Standard

1304.24(a)(3)(ii)

(ii) Promote children's mental wellness by providing group and individual staff and parent education on mental health issues;

Rationale:

A well-planned education program on mental health issues enables parents and staff to be supportive of children's mental wellness.

Related Information:

See 45 CFR 1304.40(f)(4) on a mental health education program; and see 45 CFR 1304.21(c)(1)(iii) on integrating mental health education into program activities.

Guidance:

Grantee and delegate agencies, with the assistance of mental health professionals, provide a variety of opportunities for parents and staff to learn about mental health issues, including specific guidance on how to seek help. Staff and parents are encouraged to seek individual assistance, either by scheduling an appointment or by participating in group education opportunities. Families and staff also are encouraged and supported in strengthening ties with each other, and with extended family members.

Parent group meetings provide excellent opportunities to discuss approaches that parents have found helpful in their efforts to meet their children's needs. Parents may, in turn, be helped by talking about their own experiences and by learning from one another, as well as by reading and listening to materials presented in workshops or during formal presentations by guest speakers. Parent group meetings also provide opportunities to include and seek guidance from extended family members or persons recognized as mentors by cultural tradition (e.g., Tribal elders and spiritual healers).

Information about mental wellness can focus on a wide variety of topics including:

• childrearing practices and concerns,
• childhood fears,
• helping children adjust to changes in family circumstances, and
• domestic violence.

Posting a schedule of agency visits by mental health provider(s) gives parents and staff the opportunity to speak with them in an informal manner.

Performance Standard

1304.24(a)(3)(iii)

(iii) Assist in providing special help for children with atypical behavior or development; and

Rationale:

Because children with atypical development may present unfamiliar behaviors, parents and staff benefit from opportunities to discuss with the mental health professional ways of structuring the child's program and implementing strategies that will foster development.

Related Information:

For further guidance on serving children with recognized disabilities, see 45 CFR 1304.20(f)(2), 45 CFR 1304.21(a)(1)(ii), 45 CFR 1308.19 and 45 CFR 1308.21.

Guidance:

Mental health professionals provide information on and assistance with identifying situations that require treatment. Professionals also help make appropriate referrals, visit homes (to provide suggestions for modifying the home environment), observe classroom or group socialization experiences (to provide suggestions for modifying the program to meet the needs of the child), and support parents and staff in their efforts to help the child.

For some children who are recognized as having a disability, mental health professionals help parents and staff gain access to community agencies, to ensure that the Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) is properly implemented. All work is performed in collaboration with the content area expert in disability services.

Performance Standard

1304.24(a)(3)(iv)

(iv) Utilize other community mental health resources, as needed.

Rationale:

The mental health professional assists staff and families to make contact with and to take advantage of any and all existing resources that promote the healthy development of children.

Related Information:

See 45 CFR 1304.41(a)(2)(ii) for information concerning community partnerships.

Guidance:

The mental health professional who provides regular on-site consultations assists staff to locate providers for an individual child or family who would benefit from such services. The Health Services Advisory Committee also may be of assistance in locating community mental health resources.

In addition, the mental health professional assists agencies in accessing community resources by training staff in the referral process. This understanding of and knowledge about how to navigate the system can provide staff enhanced credibility with the involved agencies. In addition, the mental health professional acts as a liaison between the specific agency in question and the program, and advocates for the child and the family should the process slow down or become unsatisfactory.

A mental health professional, in accordance with the standards of ethical conduct for his or her practice, on occasion, may be required to decline providing services to a potential client to avoid a conflict of interest. In other cases, the professional may determine that the client's needs fall outside his or her scope of expertise. In both types of instances, the mental health professional can work with the agency to secure appropriate services through referrals.