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Washington State Strategies
- IECMH in Home Visiting (Learn more about this strategy)
- IECMH in Pediatric Care (Learn more about this strategy)
- Workforce Development (Best Starts for Kids)
- Workforce Development (Promoting First Relationships in Pediatric Primary Care)
IECMH supports in the Best Starts for Kids initiative in King County, Washington
Best Starts for Kids (BSK) is a multi-faceted initiative designed to ensure that every child in King County Washington “reaches adulthood happy, healthy, safe, and thriving.” The mission of BSK is accomplished through grants to community-based organizations and service providers, and an array of technical assistance and training supports. Voters passed the initial tax levy that supports BSK in 2015 and renewed it in 2021 to extend through 2027. Jointly administered by Public Health–Seattle & King County and the King County Department of Community and Human Services, BSK allocates funds to four strategy areas: Invest Early (50 percent, for promotion, prevention, and early intervention/treatment programs for children under age five and pregnant women), Sustain the Gain (35 percent, for promotion, prevention, and early intervention/treatment programs for children and youth age five through 24), Communities Matter (10 percent, for creating safe and healthy communities), and Results Focused and Data Driven (5 percent, for evaluation, data collection, and quality improvement). Within the Invest Early strategy area, grantee organizations apply to deliver a range of services such as: home visiting, community-based parenting and peer supports, child care health consultation, developmental screening and early intervention services, and connecting families to services through Help Me Grow.
From its inception, BSK has grounded its approach to serving families in a commitment to equity and social justice. King County is diverse; among children under the age of five, 0.5 percent are American Indian/Alaska native, 18 percent are Asian/Asian-American, 8 percent are Black/African-American, 18 percent are Hispanic/Latinx, 12 percent are multiple races, 1.2 percent are Native Hawaiian/Other Pacific Islander, and 43 percent are White. Twenty percent of the population is immigrant or migrant families, and 27 percent of the population speaks a primary language other than English. To deliver culturally appropriate services that meet the needs of all King County families in the places where they live, BSK emphasizes the role of innovative approaches developed by community-led organizations. Because these organizations have faced a range of linguistic, cultural, and organizational barriers to accessing government funding in the past, BSK has adopted a several approaches to address these barriers and build community-led grantee organizations’ capacity.
- BSK offers all applicant organizations culturally responsive technical assistance for proposal development and navigating the proposal process.
- In addition to funding evidence-based and research-informed service models, BSK sets aside funds for community-designed models, which often do not have the capacity and funding for the randomized-controlled studies that meet the evidence requirements of some funding sources. Grantee organizations implementing these community-designed models create practice profiles, which describe the population to be served and core model components, and also develop theories of change, implementation plans, and performance measurement plans.
- BSK offers its grantees support for capacity building in areas such as human resources, information technology, financial management, marketing, and data and evaluation. For community-based organizations, the technical assistance increases their capacity to collect data, make data-informed decisions, and conduct program-specific evaluations with a focus on outcomes identified by programs in their practice profiles and theories of change.
- To track desired population-level changes, BSK established indicators related to the health and well-being of King County children, families, and communities. The indicators will be disaggregated by race/ethnicity, place, gender, age, and socioeconomic status, to help ensure BSK outcomes are equitable.
- BSK offers additional ongoing supports, such as workforce development, specific to particular strategy areas.
Within the Invest Early strategy area, an important set of workforce development activities aims to build BSK grantees’ capacity to support the mental health of young children and families they serve. This effort is grounded in an understanding that mental health is inextricably linked to the broader struggle for social justice and racial equity. During the first levy, BSK’s supports for IECMH comprised four strands: a landscape analysis, training, reflective consultation, and infant-early childhood mental health (IECMH) endorsement.
The landscape analysis identified strengths, challenges, and opportunities related to IECMH services in King County and led to the development of a community strategic plan. Using a community action research approach, information was collected through family and provider focus groups , and program site visits, with a focus on Black, Indigenous, and People of Color (BIPOC) families, providers, and programs.
The analysis highlighted families’ strengths, including their knowledge of child development and use of practices such as singing and reading that create positive connections with, and learning opportunities for their children. Challenges included a lack of services that are culturally relevant or available in families’ preferred languages, logistical barriers to accessing services, and not enough services county-wide. The strategic plan identified five priorities:
- Promote social and emotional well-being for all children and families
- Connect more families with IECMH services, including promotion, prevention, and treatment
- Provide high-quality, culturally relevant services that meet the needs of families
- Support all direct service providers across the continuum of care
- Build and strengthen a network of IECMH services county-wide
BSK offers monthly trainings focused on supporting infant-early childhood and parent mental health to all grantees in its Invest Early strategy area. The trainings are currently offered virtually via Zoom and are four hours long, including time for small breakout groups. They are typically delivered in English with interpreters available, with Spanish, Chinese, and Vietnamese the most common languages for interpretation. Spanish-language and American Sign Language trainings have also been delivered. The BSK IECMH Lead sends information about upcoming trainings to grantee organization directors, who share information with staff; attendance has snowballed through word-of-mouth referrals. Session attendance is between 75 and 125 participants, with a core of approximately 75 percent returning each month. The switch to virtual Zoom trainings led to an increase in the number attendees (75-125 versus 35 for in-person trainings), in the proportion of direct service providers attending compared to supervisory staff, and in the ability of providers serving rural areas to attend. The high rate of attendee retention and participation in the small group breakout sessions have allowed participants to build strong relationships with each other, make connections between training content across sessions, and bring what they learn back to their organizations and to the reflective consultation groups (see below) offered by BSK. Topics have been identified through grantee surveys. The BSK IECMH lead identifies trainers who can address requested topics, and together they develop training content. Grantees have indicated their interest in clinical work with families that is grounded in social justice and equity. Training topics such as trauma-informed practice, infant mental health 101, reflective supervision, maternal health, and attachment are therefore considered in a broader policy and societal context. For example the impact of separations at the border and fears about family separations among immigrant families served by BSK is addressed in trainings. This perspective aligns with the experiences and concerns of BSK service providers and families, many of whom are BIPOC. Virtual delivery has also allowed for collaboration with an array of expert BIPOC trainers from around the country.
BSK offers monthly 60-90-minute group reflective consultation to all grantees. While the concept of reflective consultation was new to many grantees, participation has grown to 97 groups of 6-8 members each, served by 20 reflective consultants who contract with BSK. In almost all cases each group is comprised of members working at the same grantee organization, with direct service and supervisory staff participating in the same group or in separate groups. During reflective consultation, participants examine practice experiences, including their own responses to adversities faced by families, in a supportive, non-judgmental community.
Regular evaluation data collected from reflective consultation participants revealed that the locally recruited consultants, who have strong clinical IECMH experience, were not as adept at addressing concerns related to social justice and equity, including implicit bias, structural racism, and microaggressions. In response, BSK required the reflective consultants to participate in Intergroup Dialogue—semi-structured, facilitated meetings between members of different social identity groups to build understanding, critical self-awareness, and social awareness.
BIPOC Community of Leaders in Reflective Practice
While Intergroup Dialogue for reflective consultants produced positive feedback from participants in the reflective consultation groups, it also revealed the need to directly strengthen IECMH leadership among BSK grantee organizations with BIPOC staff serving BIPOC families. BSK IECMH strategy established a 10-month BIPOC Community of Leaders in Reflective Practice (BIPOC CoL) to build this capacity, with a focus on BIPOC perspectives. Everyone involved in the CoL were People of Color, from the trainers and mentors to the 82 participants from BSK grantee organizations. Participants included supervisors as well as a large number of direct service providers from a range of sectors: doulas, speech-language therapy, child care health consultation, pediatrics, and home visiting. Quarterly trainings on topics such as Radical Hope were followed by monthly 90-minute small group mentorship discussions to deepen engagement with the training. The three mentors are reflective consultants in King County. Many participants now facilitate peer-to-peer reflective practice at their own organizations and some take more active leadership roles in their agencies by bringing an IECMH focus to all levels of agency work.
BSK partnered with the Washington Association of Infant Mental Health (WA-AIMH) to help approximately 200 service providers employed by BSK grantees attain Infant Mental Health (IMH) endorsement. The majority of the providers were the home visitors who deliver most of the direct services to children 0-3 years . A focus on equity led to an emphasis on endorsement at the Infant Family Associate level, which requires a degree or two years of experience and is more accessible to those home visiting workers who do not have the degrees required by higher levels of endorsement. The aim was to recognize and validate the IECMH experience and expertise that these home visitors already had with a formal credential.
BSK held sessions with WA-AIMH for BSK grantees to explain IMH endorsement and its value to organizations and workers. To support home visitors with the endorsement process, BSK offered scholarships to cover the cost of endorsement and also worked with them to meet endorsement training requirements through participation in BSK’s IECMH training. Qualitative evaluation data from the endorsement process found participants came to understand that the work they do on a day-to-day basis is strongly focused on IECMH to consider themselves as IECMH professionals. Anecdotal evidence suggests home visitors who changed jobs found that the IMH endorsement credential expanded their job opportunities.
During the period of the second levy IECMH efforts related to training and reflective consultation will be sustained, with a continuing focus on BIPOC perspectives. For example, follow-up with grantee organizations revealed varying levels of support for reflective work led by staff who had participated in the BIPOC Community of Leaders in Reflective Practice. To encourage organizations to increase greater support for reflective work, BSK is offering monthly Intergroup Dialogue sessions for 10 months to four groups comprised of a total of 43 directors, CEOs, and top managers. BSK will also serve as a site for a pilot project in partnership with the Reflective Supervision Collaborative to train BSK grantees to lead reflective supervision within their organizations. An additional focus during the second levy period will be engagement with BSK grantee organizations that did not participate as extensively in the training and reflective consultation offerings during the first levy. These organizations, many of them delivering community-designed models, tend to have less experience supporting IECMH. Outreach efforts will involve learning about and addressing barriers to participation.
During the first levy from 2017-2021, funding for Direct Services and System Building to Assure Healthy Development, which includes IECMH supports, was $7,281,000. The renewed tax levy allocates $9,510,000 to systems-building for IECMH from 2022-2027.
evaluation and monitoring
BSK established indicators, which are available on a data dashboard, related to the health and well-being of King County children, families, and communities to track desired population-level changes. Data for these indicators come from a range of sources, including the Best Starts for Kids Health Survey of parents/guardians in King County. A number of indicators relate to IECMH: access to needed mental and behavioral health services, child excluded from child care or preschool for behavioral reasons, families who are supported and connected (e.g., availability of emotional support for parenting), and flourishing and resilient children.
BSK also asks grantees and partners to provide data related to a range of performance measures for tracking the use of its strategies. An annual survey asks grantees about their participation in and experience of IECMH trainings, reflective consultation groups, and endorsement. These performance data have shown:
- 94 percent of the 137 providers who initiated the endorsement process reported the endorsement process was responsive to their needs and experiences; 88 percent reported an increase in confidence in their roles as an IECMH provider; 57 percent reported the endorsement process increased their effectiveness in their role with families; and 80 percent reported the endorsement process increased their preparedness to work with families;
- Among participants in reflective consultation groups 75 reported increased confidence to talk about social and emotional development with families; 94 percent reported that reflective consultation was respectful of their community’s needs and experiences; 86 percent reported a positive impact on their relationship with children and families; and 76 percent reported an increase in awareness of their own implicit biases as a result of participating in reflective consultation.
In addition to the performance measure survey, the BSK IECMH team collects evaluation data immediately following each training to learn about participants’ experiences and inform future training offerings. Data are also collected on how trainings inform participants’ work. A separate in-depth evaluation of the BIPOC CoL examines participants’ experiences of the collaborative through a range of storytelling modes such as participant writing, video, and voice recording.
Special thanks to Alicia Martinez, Best Starts for Kids Social-Emotional Wellbeing Lead, for providing information for and reviewing this profile.
Last updated June 2022
IECMH in Pediatric Care: Promoting First Relationships in Pediatric Primary Care
Since 2016, a growing number of pediatricians in Washington State have been trained on Promoting First Relationships in Pediatric Primary Care (PFR-PPC), a manualized program for pediatricians to help them support stable and secure relationships between parents and their young children. The model is an adaptation of the Promoting First Relationships (PFR) 10-week evidence-based home-visiting program that uses video feedback and consultation strategies to promote positive parent-child relationships. The pediatric adaptation gives providers insights and tools that can be used during 20-minute well-child visits.
In 2012, pediatricians who had taken a PFR workshop reported that the PFR program offered new, helpful insights about helping families with common difficulties related to feeding, sleep, and challenging behaviors. The pediatricians asked to work together with the PFR developers to adapt the model for use in pediatric clinical settings. PFR-PPC uses the consultation strategies from the home-visiting model that include: connecting with parents, supporting parents with concerns by responding to their needs, observing and commenting on in-the-moment parent-child interactions and the importance of the parent-child relationship, noticing the child’s cues, offering strengths-based positive feedback, and sharing well-timed anticipatory guidance along with parent handouts during well-child visits in the first three years. Topics addressed in anticipatory guidance and handouts include responsive caregiving, relationship-focused approaches to promoting healthy sleep and feeding, and ways to understand and help with challenging behavior. Content is delivered in a positive way that emphasizes parent strengths.
Training in PFR-PPC aims to help pediatricians better understand parent-child relationships and elements of responsive caregiving while providing tools for talking about stressors and challenging behavior. The PFR-PPC lens helps parents view a child’s challenging behavior as potentially arising from the child’s or parents’ unmet needs. This approach helps providers and families look beneath the behavior to better understand what the underlying feelings and needs might be so that parents can more effectively help the child feel less distressed. For example, understanding a worried young child’s need for reassurance from a parent can help the parent provide appropriate support so that the child’s distress, which can lead to challenging behavior, does not escalate. Pediatricians are also trained to become more attentive when observing parent-child interactions. For instance, there are many opportunities, starting at the earliest visits, to notice shared attention between the parent and child. Noticing and talking about aspects of the parent-child relationship (e.g., shared attention; parents’ role in helping their child cope with strong emotions) can help parents see the importance of their role in their child’s development and well-being.
PFR-PPC has been most widely implemented in Washington State at Seattle Children’s Hospital, where it has been incorporated into training for all pediatric residents. Since 2016, 40 to 45 residents per year have been trained, for a total of more than 170 residents. Two doctors lead the PFR-PPC training, and all of the hospital’s clinical supervisors are also trained. Initial training consists of a four-hour workshop for cohorts of 4-7 residents during the first year of their residency. The residents also have access to the PFR-PPC – trained supervisors if they have questions or concerns about challenging cases. More recently, a PFR-PPC online classroom became available with additional video case studies, booster sessions, and specific anticipatory guidance information sheets that pediatricians can use in visits.
The lead doctors have organized voluntary reflection groups for clinical supervisors, beginning in 2019. The sessions involve a case study discussion and members’ reflection on their own cases and response to families. These sessions serve as a form of reflective consultation and support for the lead doctors and pediatricians who supervise the residents; both the frequency of the sessions and attendance have increased during the COVID-19 pandemic.
Outside of Seattle Children’s Hospital, PFR-PPC training is offered by Parent-Child Relationship Programs at the Barnard Center for Infant Mental Health and Development in the form of workshops and follow-up consultation. These full-day workshops are typically delivered to pediatric clinics and include pediatricians, nurses, social workers, and family navigators. More than 100 pediatricians in Washington State have received PFR-PPC training through these workshops; they have also been delivered to clinics in Ohio, Montana, Tennessee, North Carolina, Texas, and California.
Feedback from those who have taken the training workshops revealed an interest in technical assistance to further support PFR-PPC implementation. The PFR-PPC online classroom and follow-up consultation with the instructor is now being offered to support this need.
Training in Seattle Children’s Hospital has recently been funded by King County Best Starts for Kids, a levy-funded public health initiative to promote resilience and reduce risk among young children. In Washington State, the Health Care Authority has funded PFR-PPC workshops that have been adapted to focus on women with opioid use disorder and their newborns.
Traditional PFR, delivered as a home-visiting program, has shown positive outcomes for caregivers and children in a number of randomized controlled trials (also see the home visiting research summary for more information). PFR-PPC has not been formally evaluated, though the developers are seeking funding for an evaluation.
PFR-PPC at Seattle Children’s Hospital is evaluated internally for quality improvement purposes every year through provider feedback. Anecdotal evidence suggests that PFR-PPC-trained pediatricians have fewer no-show appointments, more satisfaction with clinic visits, and a greater understanding of child social and emotional needs. Additionally, providers who have taken the training rate it very highly.
A report from the Center for the Study of Social Policy on social-emotional supports in pediatric primary care included findings from case study site visits in pediatric settings implementing PFR-PPC. In these visits, staff reported better relationships with parents, and parents reported that PFR-PPC helped them support their children’s social-emotional development.
Special thanks to the following individuals for providing information for and reviewing this profile: Jennifer Rees, Director, Promoting First Relationships; Monica Oxford, Executive Director of the Barnard Center for Infant Mental Health and Development; and Jeannie Larsen, MD, Allegro Pediatrics – Bellevue, WA and Lead Trainer, Promoting First Relationships in Pediatric Primary Care.
Last updated February 2021