Building Comprehensive

Early Childhood Systems

September 13, 2006

JOE ZOGBY: Good afternoon, I'm Joe, the team leader for the state Early Childhood Comprehensive Systems grants program and I'm welcoming you to the webcast this afternoon. It's the Early Childhood Comprehensive Systems overview and policy issues.

Our main presenter will be Kay Johnson of Project THRIVE at the National Center for Children in Poverty at Columbia University. I'm replacing Phyllis as moderator. Jane Knitzer from The National Center for children in poverty will also be available for answering questions this afternoon, although she's not actually presenting. I have just some instructions to read to you before I turn things over to Kay. The first thing is that slides will appear in the central window of your computer and should advance automatically. The slide changes are synchronized with the speaker's presentation so you do not need to do anything to advance the slides. You may need to adjust the timing of the slide changes to match the audio by using the slide delay control at the top of the messaging window.

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KAY JOHNSON: Hi, thanks to you and to Dena green and Phyllis for inviting me to talk about building Early Childhood Comprehensive Systems. It's been very nice for us to be the policy resource Center for the ECCS grantees and to work with federal partners and national organizations as people across the country are thinking about building Early Childhood Comprehensive Systems. What I'll talk about today is an overview on Project THRIVE and some of the findings and lessons learned that we've had from that and I'll also be talking about another National Center for Children in Poverty project called improve the odds that has been looking at early childhood policy with private foundation support. We're really trying to put our lessons learned from both sides together and I'm going to be talking a little bit about the kind of framework that has been developed out of a group of more than a dozen national organizations and we'll find out more about who they are later.

So if I could see the next slide, please. The picture that you're looking at now actually shows me at the center of that group of children and my co-teacher there, and I really -- this is sort of just to remind those of you who know and to let others know that I've been thinking about how we could move to enhance child health and development for a lot of -- for all of my adult life. That's a picture of me when I was a childcare teacher in North Carolina. That was my first career and I worked with low income families and trying to provide child development and early intervention services to their children for ten years before I came to public health and thinking about some of the policy issues that I've been writing about for the past 25 years.

In Project THRIVE we were to provide early childhood support and we're pleased to be helping people think about how to link policies for child health, early learning, family support and across the areas.

In the next slide you get a look at our logic model, in a sense. And why are we working on policy and how can that lead to improved outcomes? It shows you that we're really focused on the better use of existing resources, particularly financing, improving the coordination of eligibility and outreach processes so children gain access to services that their families could be using, having better mechanisms that integrate service systems across -- this is some of the core work of early childhood systems building and having cross system approaches that are serving and supporting families. We see those as the elements that undergird what policy and finance decisions can do. Then that those kinds of decisions, added to program and community level decisions, might improve child and family services across systems to better implementation of programs by linking children with medical homes, by making sure that their special needs get addressed, whether their developmental needs, physical disability, social/emotional needs and other kinds of risks. That there would be better systems at the local level so that people working with children understand early childhood and have the support that they need to be competent professionals. That we're supporting families starting where they are and including them as leaders and mentors and people that help guide system decisions. And then having services in settings that families trust and having really -- thinking with attention to those children who are more vulnerable and at highest risk, that they, in fact, have benefit of our publicly financed services and we think that will, in turn, help us improve child health and development, reduce family stress, improve parenting and help parents do their job not just as home with their children but at work with their employers.

Next slide, please. So what are the states doing to strengthen early childhood systems? We have been looking across all 50 states and Puerto Rico and the territories thinking about what are states doing to strengthen their early childhood systems? Much of what we've learned have come from the reports and documents that the ECCS grantees, supported by the Maternal and Child Health Bureau submit each year. They have plans they develop and they submit annual reports. We've now looked at two years of annual reports as well as what states have projected for the coming fiscal year. We've also looked at their plans and other related documents. We've been out in the field visiting states, engaging them in conference calls and have been interfacing with other projects whether it's work at the national governor's association is doing or works that the bills project is doing, work that people are doing around early childhood mental health, we've been trying to interface with the other projects so we can understand this from the broader lens.

The next slide gives you a little bit of framing for how we've come to think about this. When I came to this project, I had to begin myself to say well, if I was looking for a good early childhood comprehensive system, how would I know one if I saw one? And really, this framing is the way that I've come to think about it and it's a way that I've shared with others that I think helps some people think about how would you know a good early childhood comprehensive system if you saw one? The grants that the Maternal and Child Health Bureau provides for this are really encouraging states to use leadership and convening powers. This is not necessarily about creating a new agency, it is not really about creating a new project. It is about focusing the attention of leadership, about building a commitment across projects in order to foster the development of early childhood systems. And really, part of the core work that these systems builders are doing is to make intentional efforts that bridge the gap between our very siloed services and systems.

May I have the next slide, please. The primary work of building a systems to systems as Charlie Brunner from the child and family policy center in Iowa and others have come to talk about this, that we really are building a system of systems, is to support integrated cross-systems development through partnerships, alliances, agreements and so forth and to use government and structural mechanisms in order to sustain the systems that are being put into place. And the linkages that are evolving.

The next slide, please. In our assessment of state Early Childhood Comprehensive Systems we looked at two major categories. The first sort is around the last element in the last slide, systems integration. How can we monitor? How can we assess how states are doing in terms of integrating to build a system of systems? First of all, we look to see whether they had a birth to five focus. Some of them it's a birth to eight focus. Some is stronger on birth to three but continues on birth to five or birth to eight and all of the Early Childhood Comprehensive Systems projects have that and the other kind of national projects that are around the country working with states have that early childhood birth to five focus. They have a system of systems approach, they are thinking about it, not just as how do we build in silos but how do we make these things work together? It's a very unique situation we have with our children before they go to school. Families get services from so many different parts of our public and private systems that are disconnected in ways that are challenging for families especially if the families are at risk. In 22 states we found a strong system of systems approach. We also looked to see whether a state was doing cross sector fiscal planning. We think that opens the door to them being able to use resources across systems so are they understanding how much they're investing in one program or another but do they look at it together and understand how they might leverage the resources they have?

How they might avoid duplication of services and so forth? 15 states have to date done cross sector fiscal planning so they understand how much they're spending on early childhood health, how much they're spending on childcare and early care and education and how much they're spending, including in that latter category on pre-K, how much they're spending on early childhood mental health, how much of their family support and parent education work. These tend to be across departments of education, health, Human Services, child welfare and so forth. Then we're looking to see do they have a parallel emphasis across the sectors? Are they building within their silos activities that are even? You know, in some states the early care and education pieces become the center of what they're doing in early childhood, or even within that maybe they're pre-K work has become the center of what they're doing in early childhood.

We look to see, do they also -- are they also thinking about early childhood health strategies, early childhood mental health strategies and again in parent education and family support. We found parallel emphasis in 43 states but actually probably only about half of those is as strong as you would want it to be to really build these systems. Are they using mechanisms for system integration. Those kinds of things might be memorandum of understanding or cross agency dollar transfers. Those mechanisms are what we believe really undergird the strategy for sustainability of these systems. It is not dependent on one leader or one group but you have institutionized the change in some way. Next slide, please.

The next factor that we looked at, as I mentioned in the slide about what were the two main areas of work that it took to do this, is around governments and structure. I guess I would begin this by saying there isn't only one government's approach in this. So I'll say a little bit more of that as I go on. But are there some kind of structural mechanisms going into place that keep this work moving ahead? One, is there a cross sector stakeholder group. 46 states have formed such a group. One of the things that we're looking at as early learning councils become law and perhaps become funded across the country is how do these stakeholder groups fit with new groups that might be focused just on education or might be focused just on home visiting? How do these cross sector groups help sustain that focus?

A second area is do they have support for local systems integration? We found that 37 states had some kind of activity that was supporting communities at the local level. There are -- we have written about nine states and what they're doing so that this translates down to providing money to support local systems integration, giving counties flexibility to make decision and charging local boards with authority to manage that blended dollar, providing staff who work at the local level, or going all the way into things like Michigan and Vermont are doing where they have formal structures, staff hired and are asking communities to engage in results-based accountability and monitor their progress. Have local plans and so forth. There are a lot of different ways this is approached. In Arizona they had a big ballot initiative. They secured a lot of money and figuring how their local system structures are going to work. This is being done with no money, lots of money and a cross the board in between. It is an important piece of this work because services are actually delivered at the community level and the better they're integrated, the better families will be served. Do they have senior level policy leaders involved? This basically is a measure of whether or not there is someone at the governor's office level and often the governor him or herself, whether or not there is somebody in the cabinet who has been involved in this work and in some cases legislators.

There are 35 states where that senior level policymaker commitment and involvement is driving some of this work. Is there a public/private entity? We don't see it as essential to success but it certainly is a measure of commitment and there are 24 states that have a public/private entity that is funded. One of the more well-known is the early childhood investment corporation in Michigan but there are many other states that have these kind of entities and other states are moving in that direction. This often brings in business community leaders, it brings in private sector stakeholders. It engages them in that statewide conversation about how we improve the health and well-being of our youngest children. And then are parent leaders engaged? We think having active involvement in families in this process is critical. We found that only 33 states had done that. We hope all states will be doing that in the future. Do they have common system outcomes and indicators? We found 20 states -- 25 states that had that. We're going to be working over the next year with states to refine some of that work and assure that all states have that kind of support to monitor their performance.

May I have the next slide, please. I'm not going to go over the list of who is in this upper quadrant but you can see the way we're looking at this is that you can cross over on one side the system integration and across the top the government structures and where states are scoring high on both of those. They really are high achievers and this -- when we do this analysis and look at the list, we find that those are states that are also widely nationally recognized as states that are high achievers in developing early childhood systems.

So thinking -- if I can have the next slide, what is in a system of systems? A lot of people are talking about this work. A lot of different organizations, states all over the country. Some people were really doing some advanced thinking about this, Charlie Brunner and the build initiative folks have really done a lot of thinking and writing about this. We have now been doing thinking and writing about this. Other organizations have and I'll show you the list of those organizations at the end of this next section. But we began as a group and we started calling ourselves the systems working group. So the systems group came up with these four overlapping ovals and I'm going to go through them one at a time fairly quickly just to give you an idea of what this means and what shared conversation we've been having about how you define this.

Next slide, please. The first oval I'll talk about is early learning and the systems group spent a lot of time trying to put words on paper that we could all agree on. In this case we said all children should have access to early care and education opportunities in nurturing environments where they can learn to succeed in school and life. We're starting from the assumption that all children need some early care in education and what we know is that virtually all children use some kind of early care in education. This includes childcare and pre-K and head start and its to fit the quality program to the child and family needs. The next oval is family support.

If I can have the next slide and then one more so I'm on slide 15 with the family support oval. Family support and we've included in this, in a sense, parenting education, but we believe that all families should have economic and parenting supports to ensure that all children have nurturing and stable relationships with caring adults. What we know is that whether it's an economic gap and one parent loses their job and their family is under economic stress or a situation where the parent has severe problems where there might be child abuse or child neglect or where the parent is depressed or a substance abuser that they aren't able to provide the kind of nurturing and stable relationships that we would wish for their children. So this really includes a range of things that address those needs and we really believe that all families in our country have some access to economic supports, whether it's the way we run our tax system or the way that we run our public financing systems otherwise. And that community level supports for good quality parenting are important to all children.

If I can have the next slide. Those special needs, early intervention as the next oval. And then if I could move on so that we are on slide 17 and what slide 17 shows is the special needs early intervention oval. What you'll notice when you get to this slide is that it is dotted. It has a dotted line and what this early childhood systems working group said is that not all children are in this category, but all systems must have services that address the needs of these children. So here we're talking about children with special healthcare needs, disabilities or developmental delays and that they need to be identified as early as possible and that we can have appropriate assessment and receive appropriate services. What we know all over the country is that there are children who have risks that we can plainly identify but because they have not developed full diagnoses for mental health problems or their disability is not severe enough, they fall in a hole in our system and aren't getting services that might prevent those disabilities or actual delays. And so we really are thinking that early childhood systems in particular need to be focused on the prevention of the worsening of the special needs that children have. So just to show you on slide 18, the four ovals again we're seeing all children need four things, the mental health and nutrition is the last oval. On slide 19 we define what we believe that is and that's that all children need comprehensive health services that address vision, hearing, nutrition, behavioral and oral health and their physical and mental needs. A comprehensive approach is what we're talking about here.

On slide 20 on the next slide you see how those pieces go together and those overlap and what we're really talking about is how do we make these systems interactive in a way that supports families for an early childhood comprehensive system?

The early childhood systems working group is defined on the next slide and we have the alliance for early childhood finance, the build initiative, the children's project. The Center for law and social policy, the council of chief state school officers, The National Center for school and poverty, the national conference of state legislators, the national governor's association, smart start assistance center. The state early childhood policy technical assistance network and that clues the work of Charlie Brunner and the child and family policy center and zero to three. All these organizations worked on developing this approach to a system of systems and all of them have endorsed it and are out in the field talking about it. So just to move on, then, to one more way of thinking about and describing what an early childhood comprehensive system is about is to talk about what policies support a comprehensive system.

If I could have the next slide, slide 23, we're going to be talking about strategies for action and finance. And we really think that the finance approaches really are fundamental for undergirding what needs to be done. We've supported ways of looking at things through The National Center for children in poverty in a way that Dr. Knitzer and I talk about for spending smarter and using the dollars we have. We are encouraging states to conduct fiscal mapping. It should say strategies and action for finance. Looking for ways to maximize existing funds, whether that's getting more federal matching dollars or reducing duplication and getting dedicated or alternate funding. States are using taxes and trust funds and those that are using corporate and philanthropic funds to get some of this work done.

The next slide, please. The strategies and actions around the mechanisms for governance in infrastructure having the formal interagency groups, a cross system data analyses and having requests for proposal to help people see how things are sin con iced. For example, in Virginia they've synchronized their requests for proposals around their various five or six home visiting programs so there is more common ground in that and those programs are encouraged to work together in a collaborative way. Having consolidated functions in an early childhood unit. Some states have undertaken this. The only way to do it and it's really not required in what we're talking about. In Vermont they ended up taking the home visiting program from the health department, they ended up taking the early childhood mental health initiative from the mental health agency. They brought that together with their childcare program, their head start state collaboration center, their Early Childhood Comprehensive Systems work and they also have brought into that the early intervention work. They're looking at how does that group of programs support families and where is the overlap and the synergy and the cross training? Whether or not you consolidate functions in one unit, building a system of systems does that kind of thinking. And then, as I mentioned, state support for local and regional systems.

Next slide. The strategies in actions around provider support and development are about monitoring performance against quality standards and benchmarks. About doing common training and about having resource and referral mechanisms that don't just know about childcare or just know about healthcare but share the perspective across them.

The next slide, please. It's also essential, obviously, when you're doing anything that involves multiple state agencies and work with communities and trying to engage key stakeholders across systems that you have to build the political will and support for investment. The case has been made very strongly about the return on investment in early childhood showing the cost of remediation versus prevention. If you start right in early childhood with evidence and informed practices and we also have a lot of information about the importance of birth to three, birth to five, birth to eight from the brain science, from neurons to neighborhoods and other work that is going on in a variety of academic centers. We have the information to build the case here and how do we translate that into both political will as well as having the public believe in what we're doing and understand that?

Next slide, please. Having shared accountability is another strategy. For example, in one state they are looking at how they can do -- use the same developmental screening tools, the ages and stages questionnaire, known as the AFQ and the AFQSE for social and emotional development. How can they use it in childcare and pediatrician's offices and head start and home visiting thinking about those common assessment tools, also common quality standards certainly across early care in education programs and how to engage in more results-based accountability and performance monitoring. Next slide, please. Now we're going to go on to talk about policy. So we should be on slide 29 policy thinking across the ECCS core components. The five core components of the ECCS initiative overall are around access to healthcare in medical homes, social/emotional development. Parenting education and family support and you can see how these can be grouped to fit with the ovals I've shown you earlier.

Now I'm going to be talking about the improving the odds work and if you move to the next slide we'll talk about health, having a medical home and mental health and social/emotional development and the state policy choices that promote access to health and mental health services. You can find more about your state and all states by going to the NCCP website. The policy choices that promote access around health and mental health are the SCHIP eligibility. States allowing temporary coverage during determinations. That's going on in 12 states and states that supplement WIC funds to help with waiting lists going on in nine states. Plenty of room for improvement particularly on the eligibility mechanisms.

The next slide, please. Improving the odds looked at state policy choices that promote quality within various areas. Thinking about health and mental health, only seven states have achieved the national benchmark that 80% of children in Medicaid receive at least one screen annually. Here we're talking about infants -- we're talking about toddlers and pre-school age children. The two, three, 4-year-olds and what we can see is that even for those youngest children, most of whom should be seen and receive more than one EPSDT screen annually, only seven states are achieving that benchmark to get the job done at 80%. It is also having periodic visit schedules for children in your publicly insured programs that meet the academy of pediatric standards and requiring the use of objective developmental screening tools so we aren't just eyeballing a child but learning about whether they're on the right trajectory.

The next slide, please. There are a lot of policy choices that fit with the higher needs and more vulnerable children. It includes children at risk, that's only six states and having -- states have the option to provide early intervention services for children birth to five and they've had that option for a number of years but no states have yet moved in that direction. Wyoming is testing the waters but they have not moved there yet. The child abuse prevention and treatment act CAPTA, required that children be referred with substantial cases of children with child abuse be referred for early evaluation and many states are having trouble with their implementation phases of this and the title V program for children with special healthcare needs too often does not engage the youngest children and does not engage children beyond a limited number of chronic illnesses and physical disabilities.

Next slide, please. These special needs children, the state policy choices that promote quality would permit the use of the DC 0-3. The diagnostic classification 0 to 3 and it would be encouraged by having reimbursement for the providers who use that. There were five states in 2006. We recently took a look at this again. We believe we're up to nine states now but it is still a low number. They requirement newborn screening for 28 conditions and do they provide for hearing screening? A set of state policy choices provide access to early care in education. Are there childcare subsidies—

>> Does the childcare subsidy program have continuous eligibility. Less than half of states. Fewer states still on the refundable tax credits on supplementing federal head start funds to reduce their waiting lists. We've made a lot of progress in our state-funded pre-K programs but still we are not up to providing that access for all of our children. Next slide, please. There are state policy choices that promote quality in early care and education requiring adult child ratios, particularly for infants and toddlers and implementing childcare quality rating systems. That's underway in many states. We would hope that it would soon be done in all states. Implementing early learning guidelines standards for infants and toddlers. Only 19 states have done that and we know the birth to three years are critical in terms of the early learning opportunities in the brain development that's going on with children.

Then finally on the next slide parenting education and family support, one of the policy choices that promote access, developing the statewide capacity for parent information center. Using state warm lines and hot lines to provide extended referrals and supporting local family resource centers with state funding. Few states are doing any of these things. Most states will be doing the parent information centers because it is supported with federal dollars through title V. Next slide, please. Parenting education and family support state choices to provide quality include paid family leave, having a TANF work requirement for single parents during pregnancy and the first year of life. Having reduced work requirement for TANF parents with children under the age of six. Less than half of states. The state allowance for parents and school to qualify for childcare subsidies. There we have the most states of any of these options. We've made that message communicated, we need to extend it to other categories. States having a personal income tax exception for single parent families living below poverty. 36 states have taken that step toward economic security for families and state maintenance of co-payments for childcare subsidies at or below 10% of family income, only 28 states.

So on the next slide I just wanted to remind you of if you're thinking about this overall, one of the diagrams that we use when we think about where are the dollars and the programs that from the public side support an early childhood comprehensive system particularly in families who use public sector resources? And we've organized this slide around those five core components of ECCS but we're thinking not only about Medicaid and the state children's health insurance program but also about Title V Maternal and Child Health Block Grant and where the community mental health services Block Grant and the child abuse prevention and treatment and the IDEA programs and TANF and the 4B and 4E should be on here and the foundations for learning. There are a lot of other smaller federal funding things that get into this but I want to close with a diagram that reminds us we really are thinking about a system of systems and the way we coordinate these dollars and services.

I haven't begun -- let's go to the next slide. I haven't begun to talk about the community level evidence-based programming that needs to go out in all of this. NCCP knows a lot about that. There are other organizations that know a lot about that but part of the translation it's not just at the policy level in system development level but making sure that the tools that communities use and the way the service is delivered are quality services and are evidenced informed practices. On this last slide you see the team that supported the work that went into the slides I've shown you today. I'm the director of Project THRIVE, Helene and Suzanne work with us and Kay is the national director for children in poverty. Let's see where we are with questions. Do we have questions, Joe?

JOE ZOGBY: I don't have any questions yet. Let me -- okay, Gail Richie. Gail is asking are warm lines for parental mental health programs and Gail is from the substance of abuse and mental health services administration?

>> Gail, this is a very good question and I would like to talk more about how states have started using the warm lines. The main example that we have and it has been evaluated is the -- what's going on in Connecticut, a program they called help me grow. This was really launched to think about how we could get the pediatricians and pediatric healthcare providers to think about their role as a medical home and refer children appropriately when they needed other developmental or mental health or other interventions. They looked at the opportunity to use the 2-1-1 warm line and created sort of a sub part of their 2-1-1 warm line that they call help me grow. The health providers can call into this line when they have a family that they want to refer. And that -- the staff on that line will help them connect the family to a resource in their community or as near to their community as possible and it is also available for parents who have a concern to call in with that concern and get connected to resources, or if they leave the physician's office with a referral for them to call that line in order to be able to get connected to further services. The evaluation of this project showed very good results. High satisfaction among the pediatric health providers, high satisfaction among the parents and a very high rate of completion of referrals. I think -- I believe Jane does and Charlie Brunner and others, we've been talking about this all over the country to see what are the implications of this for more than just the pediatrician, but particularly for consolidating and understanding and what are the community resources for parent support? I think what we learned from Connecticut is that in a lot of instances families weren't getting connected to a community Mental Health Center or a psychologist or psychiatrist practice, they were really getting connected to a parent support group to some other activity in their community that was well below what we would think of as a professional clinical visit. And so I think it has huge implications for thinking about what we do and how we serve those at-risk children who don't yet need a professional mental health intervention, as an example

.

>> We have another question from Penny Hatcher from the state ECCS grant program with the State of Minnesota. The question is, where do you see housing in one of the ovals? Possibly family support?

>> If there are no more questions I could make a comment. It is Jane, can you hear me?

>> Jane, there was a question. There was a question from Penny Hatcher. Where do you see housing in one of the ovals? Does it go under family support?

>> Yes, housing definitely -- this is Kay, housing definitely goes under family support in the way the ovals have been defined. There is more text than I had time to share that accompanies each of those ovals and we do actually make reference to it.

>> This is Jane, can you hear me?

>> This is Joe. I hear you. Okay, I don't have anymore questions, or do I have one now? I don't have anymore questions.

>> Can you hear me? Hello.

>> Yes, we can hear you, Jane.

>> Can you hear me?

>> Yes.

>> Okay. I think the issue, two comments. One is the issue about housing raises a very important question about why it's so important to link the early childhood agenda with a family economic support agenda. That is that we know that as families work more, they lose benefits and therefore really important for the early childhood people to take a look at the overall set of benefits that the states are implementing. The other issue that I thought would be useful to raise is I think we've made great progress in building collaborations across the states. I think there are two tough issues we now need to deal with. The first is really figuring out how to pay for research informed effective practices. What we pay for is not always effective. And the second, I think, Kay highlighted throughout her talk, which is how to mobilize a different level of support for the 1/3 of young children who really face multiple risk factors. And I think those are the two emerging challenges as we continue to work to improve policies and practices to fit into the ovals. I think we also have to think about those next challenge issues.

>> I think you're absolutely right, Jane. We have particularly the challenge about getting the resources to support the informed practices.

>> The other thing I would say in this over view around systems we haven't talked as much about the work that you've led and that I've had the privilege to join with you in thinking about the financing about the kind of work early childhood systems grand east and others are doing related to early childhood mental health across the country. Do you want to talk about that for a moment?

>> Well, I think what's happening around the country is that states are really recognizing and communities are really recognizing the importance of paying attention to social and emotional development and beginning to try to build a layered system. For example, that provides support to childcare and pre-K teachers who really don't always know about how to support positive behaviors and regulatory behaviors in young children. We're getting increasing research showing the links between social and emotional competencies and the capacity for children to regulate their impulses and to think about feelings and success in early literacy and all the hard core early learning tasks that we're asking them to do. So that's one level. And I think that states are beginning to try to respond. We could use a little more help from the feds but to build networks of early childhood consultants. The other layer, I think is implicit in Gail's question, which is the invisible mental health issue that is also beginning to surface for young children is parental risk factors like maternal depression, which is really widespread in early head start, for example, almost half of the sample of women scored in with multiple depressive symptoms or in the range of clinical depression. And we know that maternal depression really impacts parental capacities across the board, asthma management, bonding, all kinds of key issues. And so I think what is happening is that the early childhood community is stretching the definition of health and mental health to really include a family focus. But this is happening very slowly. So in effect we're trying to create a two-tiered early childhood mental health component to the existing early childhood system.

>> I think that's a good way to frame it, Jane. Part of the reason we arranged this call is that some of the federal partners who work on mental health services and child welfare-related services were thinking about what is the fit of their work within these system development efforts? I think we want to be sure that people are using evidence-based practice, people are using federal dollars appropriately but maximally and that we want to be sure that there is a lot of cross fertilization between some of the really best practices that are going on in certain states, whether it's the child's individual mental health need in helping the family address and cope with that or whether it's a family issue, which it most often is for these youngest children and figuring out how to use an appropriate family approach when the mom is depressed or the child has emotional behavioral difficulty.

>> In fact, Kay, that leads to one of the most important ways in which the best early childhood mental health strategies are emerging. They're bringing the services and supports to families and children and care providers into the settings where the children and families are -- that they trust and I think that was up on your -- the logic model for Project THRIVE but I think what's really important to understand is that early childhood mental health is not putting babies on the couch, it is really helping the people who work most directly with the babies, with the toddlers and with the pre-schoolers and that in turn poses some very tough fiscal challenges because it in many cases precludes the use of Medicaid which requires an indicated client to be the child mostly, not always, and also a diagnosis. So we have some tough policy issues, but the paradigm and the emerging work, for example, there is a randomized control study going on of embedding cognitive behavioral therapy in the home visiting that is showing promise and really interesting work going early head start. We have an emerging set of strategies we can continue to test in different circumstances that will really take us to a new level of thinking about early childhood mental health and that we're really dealing with early prevention and early intervention in a way that is very powerful.

>> Joe, have you heard other questions from our call participants?

>> Yes, we have more. Theresa Miller. She actually has two questions but I only know how to bring one up at a time so I'll give you the first one. Could you, Kay, please define stakeholder as used in the presentation?

>> Very good question. The stakeholders are really quite an array of people. We actually have a graph I did not include today. They include an array of people from various state agencies and in most situations they really have in their early childhood comprehensive system efforts they have people from across what you would define as the key agencies and departments. There also are parents involved, there are people from academic settings, private practice leaders, you know, we all know the kinds of physicians and mental health professionals as well as people who are leading -- run community programs who get actively engaged in policy and program discussions at the state level. An array of those types of individuals. In some cases and some states tribal representatives, they certainly have included professional associations as well as the key organizations concerned with young children in their states. So if their state had an infant mental health association, for example. If their state had -- their American Academy of pediatrics chapter and so forth. So these stakeholder groups that have been brought together in the states really have an array -- for most states they have four, six, eight subcommittees who are off working on issues so they might have a subcommittee for each of those core areas of work and concern and then they might have a subcommittee that is just working on indicators and evaluation and another that's just really focused on doing the fiscal analysis. So it includes a pretty wide array of people. The list when you put them all together tends to run from 40 to 100 people who are actively involved in the systems development conversations, planning and implementation of plans.

>> Can I just take a quick stab at that? I want to build on what Kay said. I think that's the picture of what is. But I think that in truth a lot of the core stakeholders have come from the effort to get childcare, pre-K and head start talking with each other. And now through the ECCS bringing health and mental health to the table and I think there is a whole challenge of also making sure that we include child welfare in Part C and that all of those people are engaged deeply, not marginally, in the developing of the state vision.

>> Thank you, Jane. We have another question from Gail Richie. How do we find 1/3 kids at risk?

>> I didn't hear the question, I'm sorry. Where do we find them?

>> How do we define them? Oh, the data on -- we did actually for improving the odds and analysis across the State of children who experience three or more demographic risk factors and that's improving the odds and on the average it is about 10% of children, but most studies show -- particularly with children who are at risk of social and emotional poor outcomes anywhere from 25% to 1/3. We actually are trying to do an analysis right now to get a little bit more deeply into the different kinds of research that supports an analysis and a better answer to your question. We don't have really great epidemiological data. We do know, however, in the early head start data that children and families who experience four or more demographic risk factors didn't benefit from the early head start experience in the same way other children did. The reason at NCCP we take it so seriously, we think it has implications for the intensity and the nature of the interventions that will be necessary to get these kids back on an age-appropriate developmental track.

>> Another question, Joe?

>> I have a question from Elaine Fitzgerald, a project director for SAMSA funded early childhood system of care project in Connecticut. The question is, help me grow as one of the partners as we enter our third year. But what recommendations do you have to move our programmatic efforts to more authentically include the voice and collaborative efforts of regional and state partners?

>> I guess there is a lot of variation. The first thing I would say there is a lot of variation in this from state to state. The second thing I would say about this is that there are a lot of challenges and, as you say, authentically engaging people. I think one of the things that I know, and Jane can say more about this, that NCCP has been thinking about is how do you develop the sort of tools and strategies and learn from others who have effectively moved this conversation to the community level? We did a short report. We call them short takes on the issue of local systems development because we feel it's so important. That's where families live and work. It is where providers actually deliver services. And in a lot of ways, what people do at the state level or should be doing at the state level is to create the programs, policies and flexibility to get out of the way so this can be done to both support communities doing this and get out of the way so they aren't hindering communities from doing it. I think the more authentic involvement is going to happen as this transitions to the community level. I was in Arkansas yesterday and the day before, however, and as we talked about it there and as I reminded them, if the state and federal people do not do their work, then the communities are really hindered from that kind of activity.

>> I think the policy issue is huge in the sense that I think that the children who show signs of risk and need something other than what they get in general early childhood programs, or if they have a disability that is significant enough to be diagnosed, we really need some kind of steady funding stream for them rather than demonstration programs that come and go. And I think the states are trying to do this sometimes, for example, around the developmental screening and then allowing for a certain number of follow-up visits. We had a piece of federal legislation called the foundations of learning bill that would have allowed for six kinds of strategies to see if a quick response would help. I think we actually have a policy challenge in how we frame a reasonably accountable and cost effective way of mobilizing services around these children because I think that's what stops the community from really responding more authentically. They don't have the dollars to do it in a consistent way.

>> I'd be interested if people disagree with that but that's at least what I've seen and heard.

>> More questions, Joe?

>> Yes, I have a question from Yvonne. Are there set guidelines available for programs that are interested in implementing a warm line?

>> Hello?

>> We're not hearing you, Joe.

>> Okay. The question was from Yvonne and it was are there guidelines for implementing a warm line?

>> I think if you wanted to learn more about this, that the Connecticut folks, they both have a nice evaluation document and some other background documents on how they went about it. I know that Charlie Brunner has been doing some writing at the child and family policy center about how to translate this for other states, so there are some basic things. Most states now have some kind of a 311 system. The question is really is what do you want to build that is sort of a specific module in your 311 system and how would you want to promote and advertise it, what services and resources, information would it provide? So it could be just part of a large 311 system but I believe what they observed in Connecticut and others believe is that where you segment it off and you make it clear to people that it's for questions for families and providers about young kids at risk or who need a community referral, then families feel they have, you know, a line to call into and the calls get channeled directly there. They don't have to state their whole problem to two people sort of thing.

>> One comment from Joe. Did you mean a 311 or 2-1-1?

>> I do it all the time. Thank you. 2-1-1. I think my slide is even wrong.

>> Thanks, Kay. We have another question from Francine Fineberg. Are you aware of the family treatment that is used by SAMSA which treats the women for substance abuse and mental health disorders with histories of trauma at the time and integrated with screenings assessment and treatment for their children who obviously are affected by maternal substance abuse? The systems around this do not seem to be included.

>> This is Jane. Yes, we're aware of it and that's what I meant when I said I think we need to bring in the systems that deal with substance abuse, domestic violence, child welfare into the thinking about how to build an early childhood system that is robust enough to deal with that. The other issue is that many of the kinds of programs you just described like the family treatment have a very difficult time once the demonstration of the research component is ended sustaining themselves because it's very difficult to put multiple components together to serve young children and families and frankly substance abuse has done a better job than mental health. I would love to learn more about what you're talking about.

>> Thank, Jane. We have from Lorraine Clayton, who is the state ECCS director in Idaho, she submitted what she called a general comment but I see it as a question. That is, when a state has multiple needs and very limited resources, how do we prioritize what comes first?

>> I would like a go at that first and Jane will have something to add. This is Kay. I think that the system analysis and the fiscal scan are fundamental to understanding the resources that you have. And my observation is that every state is spending more money than it thinks it is, they are, on young children, and spending that money in less efficient ways than they might. So I think in virtually every state -- I may be wrong in your state -- but in virtually every state I observe that once those analyses are done there are overlaps, there are opportunities to streamline and build efficiency of scale and chair training dollars and reduce the number of case managers who see certain kinds of families and get the right case manager and the right services to that family. Those are the kinds of things that I think systems thinking can help you do in any time of limited resources. And I would just make the observation that in the states that we often talk about that have big sort of high profile initiatives, whether it's a Vermont or a Michigan, those are two where I understand even down to the more detailed level what they've done. They've done that without really a lot of new money in most instances. Much of what they've done is without a lot of new resources. When you start hiring staff people at the community level, those kinds of things do require new resources but a lot of the changes that states are making do not involve a major infusion of new funding at first.

>> Thank you, Kay.

>> I would say this is one of the reasons why having a cross system framework for doing the fiscal analysis becomes so important. And one of the things that some of the states have done is taken the five ECCS priorities and looked across the systems, the agencies, to see what they're funding that has to do with each of the components. It is a way of de-siloing and figuring out where there are some dollars that are being put together. I would absolutely agree that's the very first step to do.

>> Lorraine and others may know that we did a little report about where to get started on that kind of fiscal analysis and you can start with one simple table and then it can get very complicated but I would urge you, if you haven't, to start with the one simple table based on what you know agencies are spending on key programs. It is a way to begin the conversation. I would give one further example. In Massachusetts when the commissioner of health and the commissioner of education and the commissioner of child development and childcare were mandated by the legislator to do their systems review, they used that as an opportunity. And at the end of it, the commissioner of education had a multi-million program that he said this program doesn't belong to us. We're not doing this work efficiently. This should will be integrated with childcare and moved the money out of his budget into the childcare unit. That kind of thing can happen with small and large amounts of dollars when people really take a look at it.

>> Thank you, Kay. Kay, we have practically identical question from Penny Hatcher from Minnesota and Gail Richie from SAMSA and basically it is will we have access to the slides at a website? Gail's comment is they're very instructive.

>> Do these slides get archived as a part of the MCHB/CADE mechanism? Will we put them at Project THRIVE. It is www.nccp.org/THRIVE so we'll post them there. I thought they also got web logged at MCHB.

>> The webcast itself will be archived and the slides will be part of that. I'm not sure of how many days after this presentation, but it will be available, I believe, within a week. Let me see if there are any more questions.

>> I'm wondering if we have further questions.

>> I'm looking. Yes, Shirley Pitts from Alaska ECCS. People seem hesitant to share their fiscal information. How do you take the fearfulness out of this?

>> It was a good question. We did writing and interviewing of people who had done it successfully to find out because we understood it was a question. I think starting with the basic table is the way to get this underway and the basic table you end up with about ten dollar amounts. What are we spending on head start, what are we spending on childcare and Medicaid for children under six, those kinds of basic numbers. At that level it doesn't seem hard to get the numbers. And then once you have those numbers, you know, moving to the next level of the conversation seems a little less threatening but a lot of the numbers that you need to start are already in public documents, in budgets. Occasionally you have to go, like in the Medicaid you have to ask for a sub number of all of that. Or getting someone else to ask. Is there someone in the governor's cabinet or somebody at a director's level who can just ask for the number within their agency and then you put them together?

>> The other thing that I would say, I just want to mention that to get the table that Kay is talking about you can get it through the Project THRIVE part of the NCCP website so you might want to take a look at that. I think for those of you actually thinking about doing this, taking a look at the specific -- your specific state profile, for example, in Alaska or Idaho to see where the kinds of overall picture of state choices that you're making across the domains that impact early childhood -- comprehensive early childhood system development would be another useful tool for you to look at and perhaps go over with a group in order to set the stage for being willing to do the fiscal analysis.

>> Very good, Jane. As a reminder to people at the NCCP website in the improving the odds section or you can link it to early childhood as a topic, there is an individualized profile of your state based on the kinds of policy choices we talked about today.

>> Okay. I don't have anymore questions here.

>> I guess I would close by saying we are really looking forward to this coming March to having both bringing together the ECCS leaders and coordinators from around the country for a discussion of the next steps or reinforcing what they've done and sharing the learning from what has gone on in ECCS but I think particularly we're really looking forward to doing some of what Jane described, thinking about how we can better link the mental health, the substance abuse, the child welfare sides of state systems to what is going on in early childhood and how we're thinking about prevention and families at risk. It is key work. We all know those are some of the most vulnerable children and I -- having them -- having those systems included in the system of systems discussion is key if we're going the talk honestly about doing prevention and early intervention.

>> And I want to just echo what Kay said and also I think it's really exciting to be having this call and bringing together people who are sitting in different parts of the picture and I just want to say -- and I know I speak for Kay, that we're happy to continue the conversation with any of you through emails or whatever is helpful to you in what you're doing.

>> Kay and Jane, for your convenience could you say what your email and other contact would be like phone number if you wanted that?

>> You can reach me through the email THRIVE @ nccp.org.

>> Mine is Knitzer at nccp.org.

>> Just in closing I want to thank everybody and ask you if you would complete your evaluation of the webcast and just also note that the website for the archives of the webcast are on the screen with the slides and http://wwww.mchcom.com. I guess that's it.

>> Thanks again.

>> If I failed to answer or bring up anybody's questions reprimand me. Thanks, everybody.