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Colorado Strategies
Early Child Social-Emotional and Risk Factor Screening and Response and Infant and Early Childhood Mental Health (IECMH) for Vulnerable Children: ECHO and Family Center Early Childhood Council in Fremont County, Colorado

In Fremont County, Colorado, the ECHO and Family Center Early Childhood Council (ECHO) serves as a central early childhood screening and referral hub for the county, collaborating with local child welfare, mental health, health, early intervention, and early care and education providers and agencies. ECHO screenings, for children birth to five, are free for families and take approximately 90 minutes. The screening process assesses vision, hearing, communication, speech-language, social-emotional, problem-solving, and motor skills. Instruments used during an ECHO screening include Ages & Stages Questionnaire:3(ASQ-3) and Ages & Stages Questionnaire: Social Emotional-2(ASQ-SE2), both of which are parent report play-based tools. Vision and hearing screenings are also completed as part of the overall process.

The screening intake process is completed with caregivers using an informal interview format which offers an opportunity to explore family health/mental health and potential concrete needs. Selected community partners are trained and certified by an ASQ trainer of trainers to conduct the screening process.

The universal referral form developed by ECHO Council is provided directly to all community partners. Families can contact the ECHO office directly via the information provided on the website. The Partners in Early Childhood Education Services (PIECES) collaborative is specific to the partnership with Fremont County Department of Human Services to support children involved in the child welfare process. A PIECES referral includes options for an ECHO screening and direct referrals to the full spectrum of services offered by ECHO partners.

ECHO aims to ensure Fremont County children from birth to age five receive an annual screening. Partnerships with Head Start, Early Head Start, Parents as Teachers, and other agencies make it possible to record individual child screening results securely maintained in a database with intentional follow-up for re-screening with families who score in the near-positive range. ECHO offers regularly scheduled community screening days throughout the calendar year.

For families of children whose ECHO screening identifies a need for further assessment or evaluation, ECHO can refer to necessary services, be it medical, family support, mental health, or case management programs, e.g. home visitation. ECHO collaborates with Common Spirit St. Thomas More Pediatrics and private practice physicians.

Families may be referred to the Early Childhood Mental Health Hub where a multi-agency team of Early Childhood Mental Health (ECMH) Specialists determines the best provider and services based on the individual needs of the families. Services include parenting classes, consultation and/or clinical treatment provided through Crib to Kindergarten, an infant early childhood mental health (IECMH) program. Referrals supported through the ECMH Referral Hub also include Perinatal Mental Health; Early Intervention (EI) and Preschool Special Education; home visiting (Early Head Start, Nurturing Parenting, Nurse-Family Partnership, Parents as Teachers); early care and education programs (Universal Preschool-UPK); and the county maternal wellness network for mothers who screen positive for perinatal mood disorders or depression.

Evidence based parenting classes include Circle of Security, which supports healthy attachment and relationships, and The Seedlings Class, which provides an opportunity for caregivers to learn about the way stress and adversity affect their brains and bodies, as well as how it impacts their developing young children. Caregivers learn strategies to manage this stress for themselves and ways to buffer the impacts on their children.

Crib to Kindergarten providers are licensed mental health specialists with expertise in the development and mental health needs of children from birth to kindergarten entry age. Providers have been trained through the Irving Harris Program in Child Development and Infant Mental Health through the Colorado University Anschutz Psychiatry Department. Services include parenting classes, IECMH consultation for families and early care and education settings, individualized clinical treatment, and Perinatal Mental Health services for pregnancy related mood and anxiety disorders. Providers are part of a multi-agency partnership from the ECHO Council/Canon City Schools, Common Spirit Pediatric Office, and SolVista Community Mental Health Center, as well as private practice providers in the community. Referrals are staffed twice monthly through the ECMH Referral Hub, with representatives from the Hub also seated on the County’s Child Protection Team as consultants on child welfare cases and potential services.

The Colorado LAUNCH Together Initiative was funded through a consortium of eight private foundations to develop county-based referral hubs for early childhood mental health services. Together, communities and healthcare providers continue to work to integrate behavioral health services into primary care settings and offer IECMH training for specialists based in primary care practices. In Fremont County, referrals are facilitated using the universal ECHO referral form, and its six healthcare practices can support families’ engagement with their behavioral health integration social worker, who supports screening and follow-on referrals to ECHO partners. Three IECMH consultants are currently funded and work with ECE settings, in the home, and with foster caregivers.

For young children involved in child welfare, Fremont County Department of Human Services, through a memorandum of understanding, utilizes the PIECES referral form to connect families to concrete support services. Child welfare caseworkers use the PIECES referral pathway to engage all children with a child welfare investigation in an ECHO screening. Caseworkers can use PIECES to refer families directly to the ECHO partners, such as Crib to Kindergarten, early intervention, and home visiting.

The county child welfare agency has a team of caseworkers dedicated to supporting ongoing cases for children under 6 years of age. This team can re-refer children for an ECHO screening if concerns emerge after initial involvement with child welfare. The team works to support families’ understanding of the ECHO process and how it interacts separate from the child welfare system. This supported understanding increases the likelihood that families will follow up on ECHO referrals. ECHO and child welfare work collectively to engage families who may be non-responsive or hesitant to access services.

Representatives from the full range of ECHO partners meet monthly and discuss how to best facilitate referrals and share information about available services. These regular meetings allow ECHO partners to ensure families referred for screenings or services receive them in a timely manner and in ways most beneficial to them.

Financing

ECHO is the designated early childhood council for Fremont County. All of Colorado’s 64 counties are covered by one of 35 early childhood councils, which are funded through the Colorado Department of Early Childhood and other grantors as determined by each Council.

Evaluation and Monitoring

The ECHO data system collects demographic details about each child who completes screenings including the outcome of each screening. An example of this data from 2021 identified 93 children referred to ECHO from child welfare, of which 34 received a developmental screening, including 32 who received a social-emotional screening. In cases where the family was not successfully contacted or did not show up for a screening appointment, the child did not participate in the screening process.

Special thanks to Dorothy Day, Director of ECHO & Family Center Early Childhood Council, for providing information and reviewing this profile.

Last updated June 2024

Workforce Development Training on DC:0-5, Dyadic Treatment, and Parenting Programs: Right Start for Colorado

Right Start for Colorado (RSCO) is a five-year initiative aimed at expanding infant and early childhood mental health services across Colorado communities by building statewide workforce capacity for professionals serving young children birth to five years of age, including both mental health clinicians and allied professionals. The initiative provides free or low-cost training on evidence-based and research-informed assessment, diagnosis, treatment, and promotion to expand the IECMH workforce and make IECMH services and supports more accessible to children age 0-5 years and their families. RSCO’s professional development for clinicians has included training on the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5); Diversity Informed Tenets for Work with Infants, Children and Families; Circle of Security-Parenting, a group parenting reflection program; perinatal mood and anxiety disorders; and soon Child-Parent Psychotherapy, a dyadic treatment model. Allied professionals, including child welfare, early care and education, and public health staff, have received foundational training on IECMH, while more intensive and tailored IECMH training has been provided to early intervention providers and is planned for home visitors.

To inform the work of Right Start, a needs assessment was conducted between July 2019 and January 2020 by the Colorado Health Institute through a contract with the Mental Health Center of Denver (MHCD) (now called WellPower). The results of the needs assessment identified the types of services that were most in demand and training needs in different parts of the state. MHCD is the grantee for RSCO, which began its third year in October 2020 and is funded through the Substance Abuse and Mental Health Services Administration (SAMHSA)’s Infant and Early Childhood Mental Health Grant Program, as well as members of the Colorado Early Childhood Funders Network.

Clinical Workforce Training

The clinical workforce refers to professionals providing IECMH treatment. The RSCO training plan for the clinical workforce is designed to impart knowledge across four main areas of IECMH clinical practice: relationship-based assessment, developmentally sensitive diagnosis, evidence-based treatment of very young children and their caregivers, and reflective practice.

RSCO trainings on IECMH diagnosis have focused on the DC:0-5: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. A 2020 state guidance memorandum issued by the Colorado Office of Behavioral Health (OBH) recommends the use of the DC:0-5 for diagnosis of children ages 0-5 in clinical practices providing infant and early childhood mental health services. The memorandum explains that OBH and the Department of Health Care Policy and Financing (HCPF) support the use of a state-specific diagnostic “crosswalk” that aligns DC:0-5 diagnoses to those found in DSM-5 and ICD-10 and provides appropriate billing codes. A copy of the crosswalk is provided in the memorandum. IECMH leaders in Colorado, including two Zero to Three certified trainers for DC:0-5 and the Director of RSCO, developed the Colorado crosswalk by adapting features of crosswalks designed by Zero to Three and other states. (You can visit NCCP’s collection of other state crosswalks.)

In its training on DC:0-5, RSCO has aimed to reach a wide variety of clinicians and allied providers, helping them gain an understanding of IECMH disorders and an appreciation of the importance of referral for treatment, when indicated. RSCO has offered two different DC:0-5 trainings: a diagnostic training for clinicians and an awareness training for allied providers. In its first two years, RSCO has conducted 9 DC:0-5 trainings, reaching 219 clinicians. The state has 12 available Zero to Three certified DC:0-5 trainers, and RSCO partners with numerous trainers to ensure delivery to various parts of the state. Trainings have reached professionals who work with infants and young children in hospital systems, community health centers, mental health clinics, ECE settings, graduate programs, and some private practices throughout the state. In 2021, RSCO will conduct two additional DC:0-5 trainings and also begin a six-month pilot of DC:0-5 virtual “office hours” to offer follow-up support for clinicians who have attended the diagnostic training. The goal is to discuss clinicians’ cases, help them refine their diagnostic skills and embed the use of this diagnostic system into their clinical practice.

RSCO also provides trainings for clinicians on Circle of Security-Parenting (COS-P), an evidence-informed group parenting program (see PRiSM research summary on parenting programs for more information on COS-P), and Child-Parent Psychotherapy (CPP), an evidence-based dyadic therapy model (see PRiSM research summary on dyadic treatment for more information on CPP).  A COS-P training in year two had 51 participants, predominantly IECMH clinicians and IECMH consultants (with a focus on those working in publicly-funded community mental health settings), but also home visitors, public health nurses, and some ECE providers. The training had 150 applicants and based on this demand will be offered annually in years three through five.

An 18-month Child Parent Psychotherapy (CPP) learning collaborative, led by a national trainer from Tulane University, will begin in July 2021 and train 50-70 clinicians, again targeting those working in publicly-funded settings. In order to promote long term sustainability of CPP in Colorado, the learning collaborative will simultaneously function as a train-the-trainer for two apprentice trainers, who are currently rostered CPP therapists. Following this learning collaborative they will be able to provide additional CPP learning collaboratives in Colorado.

In March and April 2021, RSCO is offering two trainings on infant-early childhood relationship-based assessment: the Working Model of the Child Interview (WMCI) and the Crowell Parent-Child Interaction Procedure (Crowell). Clinicians in the state will also be offered annual training on diversity-informed tenets and interventions for perinatal mood and anxiety conditions.

A key activity of years 3 to 5 will be conducting clinical communities of practice. In year 3, RSCO launched its inaugural Clinical Community of Practice and successfully recruited 8 clinicians from across the state, prioritizing high risk, high readiness areas as identified in the RSCO needs assessment. RSCO also prioritized clinicians who are Spanish/English bilingual and from diverse backgrounds, in alignment with its goal to promote diversification of the IECMH workforce. The Clinical Community of Practice is designed to impart knowledge across three main areas of IECMH clinical practice: relationship-based assessment, developmentally sensitive diagnosis, and evidence-based treatment of very young children. Trainees receive monthly trainings as well as ongoing reflective supervision/consultation (both group and individual) with a seasoned infant mental health mentor. Clinicians are also given financial support to attain the infant or early childhood mental health endorsement through the state association of infant mental health. This cohort model will be repeated in years 4 and 5.

Training for Allied Professionals

Allied professionals are involved in work that includes IECMH promotion, prevention, identification, and referral, rather than the delivery of IECMH clinical treatment.  These  professionals work in sectors such as child welfare, primary care, home visiting, public health, early intervention, and early care and education.

RSCO conducts monthly “lunch and learn” trainings with child welfare workers in Denver, targeting case workers, supervisors, and visitation staff. Topics include trauma, referrals, and promoting nurturing visitation in infancy and early childhood. In year two, 14 of these trainings reached 153 participants.

Colorado Foundations of Infant and Early Childhood Mental Health for Early Childhood Professionals and Partners is an eight-module course developed by The Colorado Association for Infant Mental Health. It is delivered over approximately 20-24 hours and introduces allied professionals to the principles of IECMH.  Using this course, RSCO reached 155 participants, including ECE providers, home visitors, and early intervention providers, in three trainings to date. RSCO plans to continue to offer this curriculum twice annually.

RSCO is also offering year-long training to a cohort of 33 Early Intervention providers to increase their IECMH knowledge and skills and to support attainment of IMH endorsement. The training is specialized for EI providers, with an initial three-day training completed in September 2020 on foundational IECMH topics including attachment, trauma, infant mental health, parent mental health, and reflective practice. Following the training, providers participate in monthly reflective supervision/consultation with IECMH mentors to discuss cases. Participants are predominantly occupational therapists, physical therapists, speech-language therapists, and other non-mental health clinicians in EI. A similar cohort training model will be offered to home visitors.

Additional ad hoc trainings offered by RSCO have included an IECMH overview for a federally qualified health center beginning to deliver perinatal services, and two self-care trainings on how to care for oneself when treating trauma via telehealth during the pandemic.

Financing

Right Start for Colorado is one of nine initiatives funded in the first cohort of SAMHSA’s Infant and Early Childhood Mental Health Grant Program. The program requires a local funding match, which is provided by five Colorado philanthropic foundations in the case of RSCO: Buell, Caring for Colorado, Community First, Piton and ZOMA Foundations.

Colorado has secured Medicaid coverage for all of the assessment visits needed to use DC:0-5 for diagnosis, which range between three and five. Additionally, Medicaid covers dyadic treatment, including CPP, with various billing codes including 90847 and 90846 (family therapy with and without client present). COS-P delivered by credentialed mental health clinicians can be reimbursed by Medicaid.

Monitoring and Evaluation

RSCO collects demographic and evaluation data from participants in its trainings. In addition, for DC:0-5 clinician trainings, evaluation data from participants examined whether participants thought training was effective, what additional supports they would like, and how they plan to use what they learned. A pre/post-test of participant knowledge showed a 30 percent increase. A six-month follow-up survey collected data on participant reports of their changes in practice following the training. These data have not been analyzed yet, but anecdotally clinicians appreciate the DC:0-5 framework and its focus on relationships.

Participants in the COS-P training agreed to fill out data surveys, which will be sent out in early 2021. The survey will ask about number of parenting groups they have offered and the number of families served in these groups. So far, since the training ended in September 2020, 70 parents and caregivers have received COS-P from the training participants. Similarly, data will also be collected from participants in the CPP learning collaborative and from the Clinical Community of Practice on the IECMH services they deliver post-training. Data will also be collected on EI cohort participants’ experiences of reflective supervision they receive.

Last updated February 2021

Special thanks to Shannon Bekman, Director, Right Start for Colorado, WellPower, for providing information for and reviewing this profile.