Mental Health Consultation in Head Start
by Kqdija Johnston, L. C.S. W., and Elizabeth Browning, M.F. C. C., National Head Start Training Contract, James Bowman Associates, San Francisco, California
In the fall of 1993, the National Head Start Health Training Project conducted interviews with representatives of more than 5O Head Start agencies throughout the country to learn about training needs. From the results, it was obvious that mental health issues were of vital and immediate concern. Many programs felt caught between increasingly disruptive and severe behavior problems in the classroom and limited mental health resources. Staff were struggling with their own unmet mental health needs. In such an environment, mental health consultation is critical.
The authors of this article provide mental health consultation to several inner-city Head Start programs as part of the University of Cailfornia - San Francisco's Daycare Consultants. Their model of consultation is designed to address mental health rather than mental illness by improving the quality of relationships in the care of children, parents, and staff
The National Head Start Health Training Program
Traditionally, when mental health professionals are involved in child care programs their efforts are often directed at the child who is having the greatest difficulty- the child who can't sit still, the one who hurts himself or others, or the one who is unable to play with his peers. It is often at this point that teachers, frustrated with difficult to manage behavior, call in a mental health consultant. The "problem child" receives individual therapy from the mental health specialist, but the teachers are given little assistance in how to help the child in the context of the group. The mental health consultant is limited to intervening in crisis situations. Unfortunately, this common scenario limits our view of what mental health really is and what mental health consultation can be.
Our model of comprehensive mental health consultation rests on the following fundamental principles:
The following case consultation at a Head Start program illustrates these principles in action:
- Views parents and classroom staff as integral to promoting the mental health of a child with identified behavior problems;
- Promotes well-being rather than responding exclusively to identified problems;
- Promotes mutually respectful, trusting relation ships among management, staff, and parents which allows for the development of similar relationships with the children; and,
- Involves an ongoing relationship with the program, rather than crisis intervention.
Tiffany is a three-year-old girl, new to her Head Start classroom, whose teachers requested consultation because her behavior had recently become very aggressive. According to the teachers, Tiffany was attacking other children, biting, pulling hair, and grabbing toys "all the time." In meetings with Tiffany's teachers, the consultant learned that several changes had recently occurred in Tiffany's life. For example, even though she had made two visits with her mother before beginning preschool and seemed to like being there, she cried inconsolably when her mother left and would not accept comfort from any of the caregivers. In addition, Tiffany had been cared for by her grandmother since infancy and was not used to sharing her caregiver with other children. And, she had been weaned from her pacifier in preparation for preschool. None of these changes alone would necessarily be very upsetting for a child but all of them together were clearly overwhelming for Tiffany.
The next step was to meet with Tiffany's parents. At the mental health consultant's suggestion the head teacher asked for the parents' help in easing Tiffany's adjust ment to the program, rather than focusing on her aggressive behavior.
The aggressive behavior, while seeming to the teachers to happen "all the time," actually occurred most often after separation from her mother and whenever the children were grouped closely together, such as at the lunch table and in the yard where children sometimes were not closely supervised.
The consultant worked with the teachers to reduce the chances of these incidents occurring again. Her grandmother was invited to come with Tiffany to help her get used to the classroom. The head teacher offered to talk with the mother daily when she greeted Tiffany to help her with the separation, and spend more time monitoring her interaction with other children. When the children were grouped together, the teacher would hold Tiffany's hand and sit close to her. Tiffany was given more space at the lunch table and the teachers increased supervision in the yard.
Within two weeks Tiffany's unhappiness and aggressive behavior were reduced dramatically and a month later both staff and parents agreed that Tiffany was managing well.
Involving Parents and Caregivers:
When mental health consultation is focused on a particularly difficult child, as it was with Tiffany, the parents are involved from the beginning. Information about Tiffany's home life is gathered and shared with the consultant. Observation of the child at the child care site is followed by ongoing consultation to the caregivers and continued contact with the family. The specific ways in which a consultant may prove useful to a family are determined by the family's needs and wishes. At times the consultant may simply help the parents acknowledge and understand that their child is having difficulties. At other times the consultant may help parents better under stand and manage difficult behaviors, like helping with child rearing issues or ensuring that parents have contact with the appropriate agencies when longer-term help is needed. Communication between parents and teachers, along with developing ways of working with the child in the classroom, often leads to the child's improved functioning.
Promoting Well-Being:
Building an understanding and appreciation of how experiences, both at home and in child care, contribute to every child's well-being is an aim of mental health consultation. Among the most important tasks is to help staff and parents focus on the relationships within which children have the experiences that cause them to develop their unique view of themselves and their world. In Tiffany's case, the consultant did not focus on the aggressive behavior as the problem. Rather, she helped staff understand the behavior as a response to circumstances beyond Tiffany's control.
Promoting Mutually Respectful, Trusting Relation ships:
The consultant was interested in staffs opinion about Tiffany's behavior and listened closely to the classroom team. Through understanding the staff's experience with a particular child, the consultant begins to build a useful relationship with staff. It is only when a reciprocal, mutually respectful relationship exists between all adults in child care that children will be treated with respect and reciprocity. The consultant was careful to treat Tiffany's teachers the way she hoped they would treat Tiffany and the other children in the classroom.
Ongoing Program Consultation:
To be effective, consultation takes place on an on going basis between the consultant and the program rather than on a crisis intervention basis. The consultant meets regularly with the classroom staff and observes the day- to-day running of the program. As in the situation with Tiffany, caregivers often request consultation for the first time when they are worried, angered, or alarmed by a particular child. But, as occurred in this case, many caregivers see that the usefulness of working with a consultant should not be limited to crisis situations. In fact, the periodic crisis is better managed when the consultant and staff have established ways of working together. The consultant's suggestions about ways of working with a difficult child or programmatic changes that might ease the teacher's work are based on staff input and a knowledge of the program's resources and limitations.
The teachers come to feel that the consultant understands and empathizes with each teacher's experience; not just their experiences in the classroom, but also the stresses and strains of program planning that impact how they feel about the job.
What is important to note about this particular case is that Tiffany was reacting to a set of circumstances over which she had no control. It wasn't possible for her behavior to change without those circumstances being examined and adjusted to meet her needs. The teachers focused on reducing Tiffany's anxiety and fear rather than holding her responsible for her difficult behavior. This careful, understanding approach made it possible for Tiffany to bond with her caregivers and to feel good about being at the center, both of which reduced the causes of her worrying behavior and led eventually to her successful adjustment.
Teamwork between parents, teachers, and the mental health consultant resulted in changes which benefited all children. Of course, in some cases it would be appropriate for the child and/or family to be referred for ongoing work with a mental health professional. In such cases, the consultant would adhere to the same basic principles to ensure that the referral resulted in a successful link between the family and therapist, and that information continued to be shared with classroom staff.