The Starting Early
Starting Smart Story

Starting Early Starting Smart (SESS) is a proving ground for identifying, refining, and documenting effective practices that engage, involve, andstrengthen families of young children at high risk. Each SESS site offers different kinds of program services, which stemmed from the needs of theirfamilies and the kinds of collaborations that were developed. Through the SESS initiative, we have learned many important lessons that can and should be made available to families, program developers and practitioners, policymakers and funders at the community, State, and Federal levels.

Some of the most promising practices and early lessons learned in SESS programs are documented in The SESS Story, which provides descriptions of the SESS programs and early lessons learned. The results of the cross-site research study will be published, as will an array of products that share lessons learned and new knowledge that has been gained. Of particular value, SESS has developed a strong network of consumer voices—parents who have struggled with substance abuse and/or mental health problems in their own lives. These parents have compelling stories, which, when shared with key decision-makers, can instigate dialogue about expanded investment in programs using SESS key principles.

The cross-site research study will provide rigorous scientific evidence concerning whether children and families participating in SESS programs achieve better access to needed services and better social, emotional, cognitive, and behavioral health outcomes than do the children and families not receiving these services. Additional products will share information about opportunities, practices, and barriers to sought after outcomes, including a look at issues of cost effectiveness, program sustainability, and a unique sub-study assessing improvement in caregiver-child interaction through video-taped observations.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its three Centers, The Center for Substance Abuse Prevention (CSAP), The Center for Mental Health Services (CMHS), and The Center for Substance Abuse Treatment (CSAT), joined with the Casey Family Programs (CFP) to carry out a unique public-private partnership designed to produce the knowledge that will justify and compel decisionmakers to make these services widely available to young children and their families, in order to preserve the developmental promise of all the Nation's children.

We are pleased to release The SESS Story. Information about availability of current and future SESS products will be published on SAMHSA and Casey Family Programs Web sites:

Starting Early Starting Smart (SESS) is an early childhood public/private collaboration effort funded by the three Centers of the Substance Abuse Mental Health Services Administration (SAMHSA) and the Casey Family Programs. In addition, the SESS program is being conducted with the advisement and investment of the U.S. Department of Education; the Health Resources Services Administration, and the Administration for Children and Families of the U.S. Department of Health and Human Services.

Starting Early Starting Smart (SESS) is a 4-year research initiative, which is designed to provide child- and family-centered programs that bring behavioral health services (i.e., mental health services, substance abuse prevention and treatment services, and family/parenting services) to families through settings regularly used by families. These services are offered in 12 communities—five primary health care clinics and seven early childhood sites (five are Head Start programs).

The goal of the SESS program is to test the effectiveness of integrating behavioral health services for children from birth to 7 years of age and their families/caregivers within their customary service settings (early childhood or primary health care). Effects on physical, behavioral, and cognitive development of integrating services are important outcomes for families of young children.

Another goal of SESS is to foster public/private collaborations, which create more comprehensive and integrated services for young children an their families. The SESS program requires collaboration among funding organizations, grantees, program participants, and local site providers. SESS grants are awared to support and invigorate community partnerships.

Collaboration requres extensive infrastructure buidling, sustainability planning, and creative methods for drawing on separate funding streams to provide integrated services within the community. In SESS a critical element to this collaboration was the requirement that mental health and substance abuse prevention and treatment practitioners integrate their efforts within those of primary care or early childhood service providers to serve families and their young children.

With a focus on service system redesign, service access and use strategies, strengthening of the home environment, and targeting benefits for children, the SESS projects have developed local coalitions that integrate behavioral health services for families through early childhood and primary health care settings.

The Study Design
The 12 grantees, working collaboratively, designed a study whereby integrated behavioral health services are delivered in typical early childhood settings. Each site has an intervention and comparison group, and each site delivers similar targeted, culturally-relevant, interventions for young children and their families. A collaboratively determined set of outcomes has been established to evaluate project effectiveness:

• access to and use of services;
• social, emotional, and cognitive outcomes for children;
• caregiver-child interaction outcomes; and
• family functioning

    The goal of the SESS research is to provide rigorous scientific evidence concerning whether children and families participating in SESS programs achieve better access to needed services and better social, emotional, cognitive, and behavioral health outcomes than do the children and families not receiving these services. SESS programs may also generate information about opportunities, practices, and barriers to sought-after outcomes. This information is critical to achieving effective public policies.

The SESS program is geographically and culturally diverse. It reaches a variety of populations including African Americans, Hispanics, Caucasians, American    Indians, Asians, and various immigrant populations in rural, suburban, and urban settings.

 

A Steering Committee—constituted of representatives of the funding organizations, the 12 collaborating grant sites, family representatives, and the Data Coordinating Center—has responsibility for designing and carrying out a multiple-site study of the implementation and effectiveness of SESS interventions. A primary objective of the research is to inform practice and policy to meet the behavioral health and related service needs of families with very young children.

SESS demonstrates dramatically that to engage families successfully, programs must tailor service intervention plans for each child and family. The plan must be culturally relevant to the child and family. It must draw on the strengths of each family and use those strengths as a resource in treatment planning to meet the needs. (See Travis' Story for one example.)

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Starting Early Starting Smart Objectives
All SESS sites:

• target interventions to very young children that build a foundation for positive growth and development,
• integrate substance abuse prevention, treatment, and mental health services into the early childhood or primary health care settings for families, and
• meet comprehensive health and education needs of families.

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Early Findings

SESS interventions are designed to increase service access and use in areas of need for specific families (parents or other caregivers) and children and, consequently, to improve family behavioral health and child outcomes. Early findings* from the ongoing collaborative evaluation suggest that the SESS interventions were successful in increasing access to services and in changing behaviors among caregivers and their children. With regard to service access, SESS families (caregivers) experienced greater access to parenting services than comparison families (caregivers); and participating caregivers in need of behavioral health services (substance abuse and mental health) have greater access to these services than comparison group caregivers. Families (caregivers) in need of behavioral health services reduced their substance use more than comparison caregivers in need, and participating caregivers reduced their use of verbal aggression significantly, while caregivers from the comparison group increased their verbal aggression. With respect to parenting behaviors, participating caregivers significantly improved their use of appropriate discipline methods and positive reinforcements for children's behavior relative to comparison group parenting behaviors. SESS caregivers also significantly increased learning stimulation in the home in contrast to a decrease in comparison homes.
 

Children also showed beneficial responses to program services. Teacher ratings of early childhood SESS participants showed significant reductions in both externalizing and internalizing problem behaviors while ratings of comparison children reflected increasingly problematic behavior.

 In summary, the early waves of outcome data across SESS sites indicate positive program accomplishments in access and utilization of needed services by participating families. Furthermore, early findings document significant improvements in caregiver behavioral health, family functioning, and the social emotional development of targeted children. These findings will be elaborated in additional reports as the final waves of outcome data are analyzed. These positive accomplishments support the effectiveness of the SESS interventions, and they punctuate the importance of the lessons learned in the design and implementation of the individual SESS programs.
 

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About the Research Protocol
All of the sites attempting this innovative work have collaboratively developed the methods to study their efforts and articulate their findings and program. The SESS research design includes six random assignment treatment/control group sites and six quasi-experimental treatment/comparison group designees. Outcome data is collected at three or four points in time for family and child outcomes and more frequently for services utilization information.

Information is colected through in-person inteviews, telephone interviews, contact logs that record program dosage, and observational instruments. A sub-study assesses improvement in cargiver-child interaction through videotaped observations.

Site level data on program desing, program implementation, and comparison group service levels is gathered through site visit interviews, observation, and document review. This data is collected using a common protocol developed by the Data Collection Center (DCC) and the Steering Committee. Data analysis designs with appropriate adjustments (e.g., covariance analysis) for quasi-experimental sites. Structural equation modeling, hierarchical linear model, and growth curve techniques are applied as appropriate.

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*The collaborative multi-site evaluation of SESS program outcomes is ongoing at the time of this writing. The findings summarized here are based on the first 18 months (3 time points) of data on service access and utilization, and on the first 6 to 9 months (2 time points) of data on family and child behavioral outcomes. All program effects are based on statistically significant improvements as compared to control and comparaison groups in each site.

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Travis's Story

Four-year-old Travis, who was in his grandmother's care, exhibited hyperactive and uncooperative behaviors and his grandmother worried about her ability to deal with his difficult behavior. Travis' mother, Jeanne, was living in a domestically violent situation, where she and her significant other were addicted to drugs. Travis' preschool teachers were concerned about his behavior and noticed that when SESS services began in his preschool, Travis showed a keen interest in traditional storytelling. He used the gymnastics program for tumbling and other large-muscle activities. He also began coming to beda?chelh for weekly counseling with a child therapist.

Within a couple of months, both preschool staff and grandmother reported some improvement in Travis' behavior. Jeanne, too, had seen improvement in Travis and was interested in having him continue to improve. Six months after Travis began the SESS program, Jeanne's significant other, Tim, entered chemical dependency and domestic violence programs, and Jeanne went into inpatient treatment 2 months later. They currently are helping each other with their substance abuse programs, and they are taking parenting classes together. Travis is experiencing success in his elementary school, and Jeanne regained custody of him. The family has been approved for a rental subsidy from the county's Shelter Plus program, and they will live together as soon as Jeanne and Tim find a two-bedroom apartment.

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The needs of the child and of the family cannot be separated. If the parent or caregiver is troubled, if the family situation is unstable, the children in the family suffer. The many needs of children and caregivers are interwoven and must be met in a way that reflects the family's priorities. A cookie cutter approach that narrowly prescribes services will likely be doomed to failure, because families will be reluctant to engage and participate in services.

SESS Offers Strengths-Based Services Drawn from Family Traditions and Cultural Background

Everyone experiences life through the lens of the culture into which they are born. This is not limited to ethnic background. Culture includes family traditions, expectations, values, beliefs, the structure of the family and its roles. SESS program staff must understand their own cultural background and how it might affect the way they react to other cultures and traditions. In turn, staff and the individual family members must acknowledge that family culture, education, and life experience are unique sources of strength. Culture is part of the resources within the family to be realized and cultivated so that a family may achieve the goals it sets.
 

Culture and tradition can mobilize families to identify and meet the needs of their young children by exploring culturally based stories, traditions, the ways that values are expressed, and how the people in that culture celebrate their hopes for their children.

 

SESS Interventions

SESS programs value and invest in the establishment of a therapeutic relationship with families and children. Relationship building serves as a catalyst

for planning services and meeting the needs of the child and family. A holistic approach is used to identify family strengths, needs, and goals. Staff and

families, in partnership, choose the services the family will receive. Some of these services include:

• Care coordination/case management
• Pediatric primary care
• Parent education; parenting support groups
• Language development
• Home visitation/support
• Reading readiness
• Domestic violence treatment and education
• Mental health services
• Substance abuse prevention
• Substance abuse intervention and treatment
• Specialty services (such as speech therapy or physical therapy)

One of the goals of SESS is to facilitate the development of personal relationships and trust among family members and SESS staff members. Initially, a family advocate develops a connection with a parent or child to explore the family's strengths and understand its goals. Depending on the site, initial contact may take place in the classroom, at day care, or through introduction at a primary health care clinic. The objective of the contact is to address the particular needs of each family. The SESS approach is grounded in the use of a multidisciplinary intervention team to develop and accomplish strength-based, family-centered service planning with families. In some situations a mental health/substance abuse counselor or child/developmental specialist or social worker may be critical to meeting the needs of the family.
 

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What Does Integrated Services Mean?
The phrase "integrated services" is defined from the family's point of view; this means that when the provider's approach to service planning is holistic and the communication style is open, families receive access to the full range of services that are most important to them for their children.

Integrated services mean that all providers have full knowledge about the services the family is using. They approach the family with an understanding of and respect for their strengths, culture, and background. Integrated services means that every provider and family member understands the purpose and goals of the service and each of them participates in the planning and decision making process of the services.

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SESS Increases Services Through Collaboration

    A critical SESS feature is the collaboration required among program participants at the national, State, and local levels. Behavioral health services are defined as substance abuse prevention, substance abuse treatment, mental health services, and family/parenting services. These areas are tied together as integrated services through the provision of family support, advocacy, and care coordination that address medical, educational and basic needs, as well as the coordination of behavioral health and other services for families. Collaboration begins with the Casey Family Programs, SAMHSA, and other Federal agencies that support the SESS programs. Collaboration is carried through to the local level where service providers work together with families to meet their goals. Collaboration within the community is necessary to develop the structure and the means to provide integrated services now and in the future.

It takes a multidisciplinary team of people to recruit the families, identify their strengths and needs, and find and agree on the services to meet these needs. Collaboration is necessary to ensure that the traditional health, human services, housing, and education service providers work with families in a collaborative manner that is child- and family-centered.

Families working with SESS programs face an array of practical, psychological, and cultural barriers to using health and education services in the traditional child care and health services system. Traditional services, based upon specific problems and reinforced by categorical funding streams, have strict criteria and procedures that narrowly define who can use the service and for what reason. SESS programs provide an alternative to the traditional health and social services system by working to provide integrated services to families. The SESS service providers understand a broad range of family needs and strengths and work with the families to achieve self-identified goals.
 

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What Does Collaboration Mean?
Collaboration components vary in different settings. Some sites have one, a few, or all of the following mechanisms to ensure effective collaboration:

• Written memoranda of understanding (MOUs) outlining the responsibilities and approach of each collaborator in working with families and their children.
• Co-location of collaborating staff members at the primary care and early childhood sites to encourage communication and teamwork when working with families and children.
• Regular management team meetings to ensure integrated services.
• Cross-training to develop the family- and childcentered approach to service.
• Joint funding streams.

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SESS Measures Outcomes to Inform Practice and Policy

    The flow of information—among collaborating staff about the families with whom they work—is key. Regular meetings (usually weekly) of the collaboration staff, to address problems and to share experiences and data, occurred in most SESS sites.

3. Co-location of services strengthen collaborative, integrated services.
All of the SESS sites co-located care coordination/ case management and family advocacy services at the primary care and early childhood sites where the children are regularly served. Location of additional collaborator staff at the primary care and early childhood site strengthened the program and its ability to provide truly integrated services to families. When services are not located at the site of the children's programs, regular meetings and communications are even more important to effect change in the traditional approach used by the agencies involved.

4. Sites had varying levels of success in introducing substance abuse and mental health services into the childcare and primary health care settings.
Training—regarding alcohol and other drug prevention, intervention, treatment approaches and outcomes—for childcare and primary health care staff is important. General beliefs about substance abuse and a lack of knowledge about how to approach the issue may cause practitioners to avoid opportunities to address the issue or encourage treatment.

 

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Rita's Story
Rita's parents divorced when she was just 3 years old. She and her four sisters lived with her mother. By the time she was 11 her father had remarried a woman who had a son the same age. She and anolder sister moved in with her father. Since the two sisters were close in age to the stepbrother, her father decided that it might be a good idea for them to live with him. She recalls not wanting to move in with her father, because he had a serious drinking problem. Also, he was not having a good relationship with her stepmother.

Rita remembers drinking alcohol with her father as early as when she was 12 years old. Not long after she began to drink, she started smoking marijuana with her older sisters. Drinking and smoking lead to amphetamines and finally crack cocaine.

At the height of her addiction, she was age 21 and pregnant. Something about pregnancy and the thought of harming an unborn child caused her to rethink the severity of her drug addiction. In the midst of self-destructivebehavior arose a maternal desire to save her child.

This saving grace, for Rita, occurred 3 years ago, during her fourth month of pregnancy. She realized that her lifestyle could potentially cause some complications for her unborn child. She admitted herself to a drug rehabilitation program at the university hospital and to date has maintained sobriety. She enrolled in Los Ninos, a service provided during rehab that monitored the development of her unborn baby.

In February of 1998 she gave birth to a baby girl. The baby suffered from social anxiety, which made it very difficult for Rita to take the baby away from home. A trip to the grocery store could prove to be a disaster. Rita carried a burden of guilt about her daughter's problems. She sought help from her caseworker, who referred her to participate in a local SESS project.

Rita participated in a number of services provided by the SESS project. Her daughter was seen regularly in the program's primary health care clinic for well-child visits. Based upon the results of developmental evaluations, Rita was referred to and received specialized early intervention services to ameliorate developmental delays. In addition to receiving case management and home visiting services, Rita attended parenting groups onsite and also accessed the free legal services the program offered.

Rita was an ideal participant. She assumed a leadership and advocacy role on the Family Solutions Committee. She credits the program for educating her and providing her with counseling services that benefit her daughter. Now, with self-esteem intact, she is important to her community. She serves as a liaison between the community and SESS. She would like to be instrumental in establishing more contact with parents in similar situations.

Rita continues to move forward and is setting a positive example for others. She volunteers as the executive parent representative on the Family Answers Committee. This committee is a group of parents that meet monthly with case managers to address parent concerns. She also works for the city government's planning department. Her job has allowed her to network with local private business owners. As a result, she has spearheaded a fundraising project. All funds collected will help subsidize fees to attend future Family Strengths Institutes.

Rita has acquired the ability to speak in front of large groups. On January 22, 2001, she addressed the State legislature concerning legislation for prenatal nutrition classes. She not only prepared the speech, she also researched all existing legislation on the subject. She also made a presentation at a symposium in April 2001. She is amazed at how much respect she is receiving from her community. She never fathomed that the experiences in her life would result in such positive activity.
 

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Key Concepts Applicable to a SESS Intervention Approach

• Behavioral health services
• Child- and family-centered
• Individually tailored services
• Culturally competent
• Relationship-oriented
• Strength-based
• Holistic
• Cross-training
• Service integration
• Multidisciplinary team
• Collaboration
• Co-location of services
• Comprehensive
• Enduring/sufficient dosage
• Prevention/early intervention
• Family as co-equal partners

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Loretta's Story
Loretta woke up and found herself in the middle of her sister's nightmare. Loretta had been a very content, single, career woman. For 8 ^1/2 years she had worked for the same company as a buyer. She was fairly well established with a place of her own and money saved. Although she did not have children of her own she was quite content being an aunt to her sister's five children.

Loretta had followed through with the plans for her life. Drugs were not a part of that plan. Drugs were, however, through no fault of her own, a major component in the events that were about to change her life forever. Unknown to Loretta, her sister was a drug addict. Since there was no previous drug abuse or use in her family, they were not familiar with the signs of addiction. Once Loretta found out that her sister was using drugs, she exercised codependent behavior. In her efforts to help her sister she would give her money, but her sister would use the money to purchase more drugs.

Eventually Loretta realized that the true victims in this scenario were the five children. They were being neglected physically and emotionally. In fact, the two youngest children were visibly suffering from malnutrition; literally starving to death. She had to step in and help her sister's children.

Looking for services to assist her with parenting, Loretta turned to Head Start and signed up for their SESS Parenting Success classes. Then she was referred to a collaborating university that provided a special 10-week program, which helped families work together with the school program. Loretta was overwhelmed with the duties that a single mother has, coupled with the special needs of a child suffering from prenatal drug exposure. It was necessary to take a 6-month leave of absence from her job. Her days were filled with taking David to different doctors, counselors, or therapists. Because of her love for her nephew, Loretta found herself advocating for him, becoming the voice of this little boy who refused to talk.

After completing the 10-week program, Loretta signed up for an advanced phase of that training. At this time she became a parent liaison and has been on the fast track ever since. She has acted as a class and school monitor for Head Start. Since September 1999, she has been an assistant teacher. David's extensive schedule did not allow Loretta to return to her job. What she thought would be a temporary situation turned into a job in and of itself. Not only does she work for Head Start, she is also the parent liaison for the three training programs from which she graduated. In June 2001 she traveled to Wisconsin to study to become a certified trainer.

Loretta is happy with the services she has obtained through SESS; David received one-on-one play therapy. Loretta was also taught the "special play" technique. David's progress has been excellent. His language skills have increased and improved. He is more cooperative and less aggressive in the classroom. His teachers say he listens very well, and he truly uses his words to express his feelings and needs. In fact David talks so much now that Loretta says, "He needs a muzzle!"

Loretta knows that a voice can be heard from any family member. She would like to see more services that cater to non-drug-using family members who have custody of the children of drug abusers. To date Loretta's sister is working in a fast food restaurant, but she is still using drugs. She has not been able to regain custody of any of her children. David is 4 years old and loves school. He has become a "poster child" of sorts at his school, capturing the hearts of the teachers and students alike because of his loving nature. The love of an aunt has been passed down to a nephew.
 

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• the effort to individualize and provide services such as transportation, language skills, etc., to meet the identified needs of children and their families, with a specific focus on mental health and substance abuse prevention and treatment services; and
• the fostering of community-based organized systems of care that create mechanisms for service integration, i.e., pooling funds, developing shared training, and developing shared plans for treatment and care management across agencies.

    Twelve communities—five private, community- based and public primary health care clinics and seven early childhood sites (five are Head Start programs)—offer child- and family-centered sustainable partnerships to integrate behavioral health services into settings familiar to children and families. The program is geographically and culturally diverse, reaching a variety of unique populations including African American, Hispanic, Caucasian, American Indian, and Asian, as well as immigrant populations in rural, suburban, and urban settings.

Both the primary health care and early childhood settings are similar in that they are guided by a complex array of statutes, regulations, and procedures that govern service provision. The host setting influences program design, emphasis, and implementation processes. Critical differences exist between early childhood sites and primary health care sites in the following ways:

Age of Children Served. Early childhood sites serve predominately children between the ages of 3 and 5, while the primary health care sites usually serve infants to 3-year-olds.

Eligibility Criteria. At early childhood sites, eligibility is determined by the setting, not the individuals within it. Entire classrooms of children are eligible even though they may not all choose to participate in the program. By contrast, primary health care sites serve a general population, which is screened to determine if they are eligible based on need and the desire to obtain SESS services. Need is identified by specific factors that put individuals at risk. Examples include families that have a history of neglect, substance use, mental health or significant parenting stress issues, or an indication to a physician or nurse (by the parent) that they are under stress due to their role as a parent. As a result of this initial screening, the primary health care sites serve a population whose environment and life circumstances put them at higher risk for developing mental health or substance abuse problems.

Family Contact Within a Site. Families have regular contact with staff in the primary health care sites during routine well-child and sick-child pediatric visits, which occur frequently in the first years of life. However, families in the early childhood sites engage with SESS staff on a nearly daily basis, as children attend the early childhood programs. It should be noted that care coordination or family advocacy is used in all SESS sites to identify and meet family needs and goals.

Early Childhood Settings

Child Development Inc. — Arkansas

Program Population

• Caucasian, African American, and Hispanic
• 3—5 Years
• Rural

Progam Services Include:

• Parenting Classes and General Parenting Information
• Mental Health Services Both Offsite and at the Head Start Centers for Children and Their Families
• Classroom Observation
• Play Therapy
• Family Counseling
• Home Family Visits
• Substance Abuse Education and Support Groups
• Substance Abuse Treatment and Referral
• Lending Library for Children and Family
• Staff Advocacy for Parents and Children
• Behavior Management Services and Referrals
• Transportation
• Flexible Dollars for Medication and Uncovered Mental Health and Substance Abuse Treatment Needs

    The Setting
Child Development, Inc. (CDI) integrates behavioral health services into Head Start sites that are located in nine of CDI's sites. The sites are located in rural counties in the River Valley and West Central sections of Arkansas. The difference between this SESS program and the other SESS programs around the country is the rural nature of the Arkansas program. The River Valley, in central Arkansas, covers four counties and has six SESS sites. The West Central region, bordering Oklahoma and Texas, covers two counties and has three SESS sites. Because the sites are scattered, it often takes several hours to travel from one site to another. In addition, collaborators are frequently located in counties that are several hours from the SESS sites. CDI served 2,064 children in a variety of programs; 1,200 of those children were in Head Start. CDI served children in 13 counties last year; SESS projects were located in nine of those counties. Intervention centers are in six counties as noted. The agency operates regional, early, home- based and migrant/seasonal Head Start in addition to other developmental daycare programs serving children age 0 to 12.

The project is a collaborative effort with University Affiliated Programs of Arkansas, University of Arkansas Medical Sciences. The UAP provides research and program support services.

The Families Served
For research purposes, this program operates two SESS treatment and two comparison groups. The first group of participants (100) and comparison group (100) included families and their children who entered Head Start at age 3, during the 1998-1999 school year. The second group of participants (60) and second comparison group (60) entered the SESS Head Start based program in the 1999-2000 school year. The population consists of African American, Caucasian, and Hispanic families. Centers were randomized based on geography, demographics, and program size. All 3-year-olds within those centers who were eligible for two years of Head Start services were recruited. SESS services were made available to all families enrolled in the center. SESS families qualified for more intensive services. The agencies' trans-disciplinary team assists in identifying, referring, staffing, and tracking those children and families with special needs.

The Collaboration
The CDI project is a collaboration between University Affiliated Programs and the University of Arkansas Medical Sciences. Collaboration activities include research, training, and consultation. Two SESS Steering Committees guide this program to accommodate program needs that are spread across two large regions of the State of Arkansas. Each committee includes parents and CDI staff as well as representatives of health services, the juvenile service providers system, Department of Children and Family Services, education agencies, mental health services, and substance abuse treatment services. CDI is closely involved through regular attendance with other county, regional, and statewide multidisciplinary teams that affect its families.

The SESS program staff includes the program director, two case managers, and one behavior management specialist for the River Valley region; and one case manager and one behavior management specialist for the West Central region. In addition, SESS contracts with Community Service, Inc., Counseling Associates, Inc., and Western Arkansas Counseling and Guidance Center to provide behavior management and mental health services. A substance abuse contract is maintained with ARVAC's Freedom House.

SESS provided 41 days of cross training for its program staff as well as for the staff of Head Start and SESS collaborators. Topics included substance abuse, behavior management, service coordination, domestic violence, diversity, crisis intervention, child abuse, and resiliency, among others. Head Start itself has an Advisory Committee in each county that includes representatives from community agencies, Head Start parents, education, and health providers. The committee facilitates service integration and provides input on the community and the needs of Head Start families.

Head Start parent groups meet monthly, and are attended as regularly as possible by SESS staff and co-located mental health and substance abuse providers. The Head Start Policy Council membership includes representatives from the community and each of the parent groups. The council has input into Head Start's decisionmaking process.

Engaging in Relationships Through Child- and Family-Centered Services
The Head Start setting provides a structured framework for the SESS program. Developmental health, hearing, speech, and language needs of each child are assessed at enrollment through use of formal assessment tools. Families work with Head Start staff to complete a Family Partnership Agreement. This assists in identifying both the strengths and the needs of families while providing a mechanism for tracking family accomplishments as well as service needs and receipt of services. The agreement is referred to continually throughout Head Start participation.

SESS staff and families engage in mutually respectful relationships when parents come to the Head Start centers to drop off and pick up their children, and for family meetings, social gatherings, and other programs. Besides being onsite to meet with families, SESS staff members maintain ongoing relationships with parents by attending Head Start parent meetings. The behavior management assistants and the case managers attend meetings of their respective sites, and the SESS-contracted mental health provider attends at least six meetings throughout the year.

Parent-Focused Services.
The Nurturing Curriculum, a parenting program, is available to all families at the SESS sites at times that are convenient for family members. A few families get this training at home to meet their individual family needs. A resource library that includes books, games, and videos on parenting, women's issues, and mental health topics is available at SESS sites. The library is open whenever the Head Start program is, and the materials can be checked out by parents and other caregivers as well as collaborators. SESS has also allocated money for food to be served at the meetings in an effort to create a nurturing environment for relationship building.

Child-Focused Services.
The SESS intervention services enhance Head Start services, especially in behavioral health areas. A behavior management associate, who is onsite 1 or 2 days a week, helps the Head Start teacher during class time, making it possible for the teacher to work with a reduced class size on those days. Mental health services are provided at the Head Start centers by licensed providers. A practitioner is available to each site for at least 3 hours a week and provides services during regular Head Start hours and after hours during parent meetings.

Head Start parents have the opportunity to meet with the mental health practitioner regularly, because they are at the site. Also, because of this the parents will be able to work with someone they've met prior to a crisis. SESS staff found that this relationship reduces the discomfort parents may feel when confronted by a problem with their child.

Three collaborating agencies have provided substance abuse services to the adult and adolescent family members at the SESS sites. However, few family members needing treatment have been identified. Individuals tend to identify other family members as having a problem. Self- disclosure has been a problem, and initially, onsite substance abuse services were not provided. Once the decision was made to bring the services onsite, there were difficulties due to the restricted availability of substance abuse counselors. As the project matures there has been increased emphasis on substance abuse intervention in addition to prevention. A contract is currently in place for onsite services to be provided by the staff of ARVAC's Freedom House.

The Challenges
The SESS sites are finding their services enhanced and supported by the SESS initiative. The program provides more focus on prevention services, more support available for parents, ongoing observation of children and subsequently earlier identification and intervention with problem behaviors, more appropriate referrals to the Head Start central office, and improved access to mental health services by children and families. Because so few families disclose substance abuse behavior, SESS, Head Start, and other collaborators are considering ways to address this behavior more directly.

SESS has realized that engaging all collaborators including mid-management and service providers is important. Staff stability greatly aids the process, as does planning, flexibility, and a realistic approach that recognizes that integrating a new service area into a childcare center takes time, and that success may come in bursts, with some pauses in between. One of the advantages experienced by the SESS sites is that behavior problems of children are better handled at the Head Start center. Fewer referrals outside the program are necessary.

An ongoing challenge has been access to social and health services in the rural communities where the SESS sites are located. Programs located in the county seats have access to a broader array of health, mental health, prevention, recreation,
 

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Head Start and SESS Have Given Me Hope For the Future of My Family

I became a single father when I came home from work and found my wife dead. I was left with a 6-week-old son and a 10-year-old daughter. My mother-in- law took my daughter to raise, and I moved to Clarksville with my son, Caleb, when he was 2. I was able to enroll my son in the Head Start program and was amazed at the number of services offered to him including dental, vision, and education services. Caleb learned socialization skills and was exposed to experiences and opportunities that I never could have provided alone. Caleb's teachers exposed him to maternal ways and helped to fill the void of not having a mother. Caleb is well rounded and has high self-esteem. He brags about Head Start being his school.

I chose to participate in SESS, because I wanted to help make a difference. I believe that education is the solution to many of our Nation's problems today and hope that I can make my contribution for improvements. The major additions of SESS to the Head Start program include the parenting classes and mental health providers at the center. Personally, the parenting classes provided an avenue to vent frustrations and to receive support and encouragement from others in similar situations. It was awkward at first being the only single father in the group, but I was able to provide a male opinion on things when asked. I was always able to take my son to the classes, because they provided childcare and food, which helped with the time constraints of being a single parent. I can't imagine life without Head Start or the SESS project. Head Start and SESS have been the light at the end of my tunnel and have given me hope for the future of my family.

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Beda?chelh (Our Children)Tulalip Tribes' Intervention In Tribal and Mainstream Communities —Washington

Program Population

• American Indian Tribal Families
• 3—6 Years
• Mainstream Families

Progam Services Include:

• Child Therapy
• Milieu Therapy in the Preschools
• Traditional Storytelling
• Nee-Kon-Nah Time Prevention Cirriculum
• Gymnastics Lessons
• Mental Health Services
• Chemical Dependency Treatment
• Family Preservation Services
• Domestic Violence Treatment
• Housing Assistance
• Positive Indian Parenting

    The Setting
Starting Early Starting Smart (SESS) is a program of the Tulalip Tribes' beda?chelh program. 'Beda?chelh' means 'our children' in Lushootseed, the traditional language of the four original tribes that came together on the Tulalip Bay as a result of the Point Elliott Treaty. The 22,000-acre Tulalip Reservation is now home to more than 2,000 enrolled Tulalip tribal members and several thousand others both Indian and non-Indian. Beda?chelh's SESS program serves both tribal and mainstream children and families. The families and children of Tulalip are contacted through the Tulalip Montessori and the Tulalip Early Childhood Education and Prevention (ECEAP) preschools. Mainstream families and children are contacted through Catholic Community Services' Childspace in Everett and St. Mike's Tikes preschool in Olympia, both of which serve smaller communities within a larger suburban setting. In both tribal and mainstream settings, beda?chelh's SESS program believes in a mind, body, and spirit approach to reducing risk factors and enhancing protective factors in children and their parents. Interventions are designed to strengthen individual skills by strengthening the bonds between children and their families and communities.
 

    The Families Served
Any family and its child between the ages of 3 and 5 who attends one of the SESS preschools may enroll in the SESS program. The SESS program serves about 100 families on the Tulalip Reservation and the mainstream sites in Everett and Olympia. Measures of these children and their families are compared with those of children and family control sites. Lummi Head Start provides the comparison to the Tulalip preschools because it is a Northwest reservation, which is similar to the Tulalip Tribes. The South Everett Montessori and the South Sound YMCA were chosen as mainstream comparison sites because they serve families similar to those served at Childspace and St. Mike's Tikes. Working collaboratively with families to help provide the best learning environment and greatest health for their children has proved to be the purest and most effective way beda?chelh has found to involve the entire family in moving toward health.

The Collaboration
The SESS team works with the co-located collaborators of the Child Advocacy Center, the Stop Violence Against Indian Women team, the child therapists who work at both beda?chelh and the preschool sites, the clinical and legal consultants, and the Indian Child Welfare case managers. Several other community collaborators meet regularly with this multidisciplinary team. Cross-trainings occur regularly and as specific needs arise.

Engaging in Relationships Through Child- and Family-Centered Services
The Tulalip Tribes beda?chelh SESS program uses an integrated, multidisciplinary approach to provide strength-based behavioral health interventions in tribal and mainstream preschools. These interventions consist of traditional storytelling and the Nee-Kon-Nah Time prevention curriculum to enhance connectedness, trust, self-esteem, and reading readiness; milieu therapy by certified therapists to increase therapeutic aspects of the preschool environment; and onsite gymnastics lessons to improve motor skills and to promote self-regulation of behavior. In addition, play therapy for the children and integrated behavioral health services for their family members (substance abuse treatment, mental health services, in-home supportive services, parenting education) are made available and readily accessible in each of the communities served.

Preschool directors meet with families and their children to describe the SESS program and invite participation in the services.

Family-Centered Services. SESS provides in- home Family Preservation Services and other support to strengthen Indian and mainstream families. Mental health services are provided onsite at beda?chelh, the pre-schools, and by collaborators at other locations. Services include individual, couples, and family counseling by certified mental health counselors along with medication evaluation, prescription, and monitoring by Tulalip's consulting psychiatrist. Outpatient chemical dependency services are offered on the reservation and in both of the mainstream communities served, and these programs help families access inpatient treatment when necessary. State certified domestic violence services are available to perpetrators and victims through collaborators, both on the reservation and in the mainstream sites. Beda?chelh also hosts victim support groups. Parenting education classes are available at all sites and families who are at risk for homelessness are able to receive housing assistance vouchers through the SESS program's collaboration with the Housing Authority of Snohomish County.

Child-Centered Services. Child therapy, both individually and in small groups, is offered by certified therapists in the preschools and at beda?chelh to enhance children's well being. The therapists work with the preschool directors and teachers to enhance the therapeutic aspects of the preschool environment. The lead child therapist observes children several times a week to help the preschool staff and teachers to work more effectively with the children. Education for preschool staff is provided upon request.

The preschool teachers and SESS staff agree with Terry Cross, executive director of the National Indian Child Welfare Association (NICWA), that the teachings in traditional storytelling are a critical untapped resource of children's mental health. These stories actively engage children in a manner that few other activities can. Storytelling involvement enhances connectedness to all life and helps children form strong characters because the stories contain wisdom about mental health, growth and development, socialization, and one's place in the world. To improve motor skills and promote self-regulation of behavior, professional instructors conduct gymnastics lessons at the preschool. Children who had not previously been able to wait in line now do this regularly as they line up for the gym bus.

Beda?chelh also has a Child Advocacy Center that provides child- and family-centered services for abused children and their non-offending family members. This program has a board of community professionals drawn from the legal, law enforcement, and medical communities to provide a protocol for a professional, integrated, supportive response to abused children and their non-offending family members. The Center then orchestrates the services needed for these children and families in a culturally appropriate manner. Beda?chelh also works on child welfare issues to help obtain the best child protection solutions for "our children" the English translation of beda?chelh.

The Challenges
The SESS program handled challenges that might occur with any new program, including resistance by some teachers to the new ideas brought to their classroom. Time, the quality and gentleness of SESS staff, and continued support by the preschool directors overcame this challenge. In addition, the SESS team members dropped the use of a screening tool they had designed to enroll families in the program because the preschool staff told them it would not be effective. Based on the preschool staff's advice, the SESS team focused on a strength-based intervention for all the preschool's children and opened enrollment to all children and their families. The lesson learned from this experience was to listen to those in the existing system and be flexible to meet the needs of the preschool and the children.

 

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Nee-Kon-Nah Time

Nee-Kon-Nah Time, a substance abuse prevention curriculum to enhance self-esteem, cultural identity, and reading readiness is offered at the preschool. This curriculum was designed as the product of the Center for Substance Abuse Prevention grant. The curriculum contains the best prevention "lessons" for preschool children that the educators at the American Indian Institute at the University of Oklahoma could find. The curriculum provides a flexible substance abuse prevention, domestic violence prevention, and mental-health-building curriculum for preschool children.

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Asian American Recovery Services, Inc. —California

    Program Population:

• Predominately Chinese and Recent Immigrants
• 3—5 Years
• Urban

    Program Services Include

• Developmentl and Behavioral Health Services
• Parenting Skills Training
• Family Mental Health and Substance Abuse Services

    The Setting
Asian American Recovery Services (AARS) is the primary grantee for the SESS Comprehensive Asian Preschool Services (CAPS) program, with Wu Yee Child Services serving as the primary subcontractor and intervention site. Wu Yee Child Services operates four year-round, full- day bilingual preschool programs serving a largely Chinese immigrant population. AARS provides grants management, evaluation research services, and substance abuse treatment services. The four Wu Yee preschools serve as the intervention sites (two in Chinatown and two in the more culturally diverse Tenderloin district), and there are two predominately Chinese comparison sites that are not part of the Wu Yee agency.

 

    The Families Served
Wu Yee preschools accept children who live in the geographic area served by the schools who meet the age and economic criteria for acceptance. Also considered are family income, the children's special needs, current sibling enrollees, and the caregivers' work, school, or vocational training status. All children who are accepted into a Wu Yee school receive SESS/CAPS services, but approximately 20 percent of the families declined participation in the SESS study.

Children who attend Wu Yee preschools are from families living below the poverty level, often in substandard, overcrowded housing conditions. Services are not abundant in the Chinatown and Tenderloin districts and few of the families in Wu Yee preschools have a history of regularly accessing behavioral health services. In many cases, Wu Yee (and CAPS) is the first place that has paid special attention to their service needs.

The Collaboration
The basic design of the Wu Yee schools has not changed dramatically since the inception of CAPS. CAPS added three additional family advocates (FAs) to the two who previously served as liaison for all families in the four schools. In addition, CAPS hired a child development director and a child development coordinator to focus on creating innovative developmental curricula that address the specific needs of children from families experiencing a variety of behavioral health problems.

The CAPS program is composed of two work groups. The first is a classroom work group made up of master teachers, site supervisors, classroom teachers, family advocates, and mental health clinical interns. The second is a multidisciplinary work group that consists of collaborating agencies to which clients are referred for services or who provide consultation to Wu Yee staff. These include a mental health counselor from Chinatown Child Development Center (CCDC), a public health nurse, a behavioral health specialist, a substance abuse treatment specialist, Wu Yee's director of child development services, and its director of preschool services. The same multidisciplinary staff members serve client families from all four of the CAPS intervention

A clinical intern from the California School of Professional Psychology is assigned to each of the four intervention schools for 8 hours each week. The intern works with those families who want mental health services, which are provided by the Chinatown Child Development Center.

A collaboration has also been established with the University of San Francisco's dental program, where bilingual dental students provide free dental services to CAPS clients. CAPS differ from other collaborations in the Chinatown area in that each collaborator has signed a formal agreement to participate in CAPS.

Engaging in Relationships Through Child- and Family-Centered Services
Family advocates serve as liaisons between families and the preschools, and have primary responsibility for identification of service needs among parents and other caregivers. They are not assigned particular families, but rather interact with all parents/caregivers when children are dropped off in the morning or picked up after school. School drop-off times are staggered, which allows FAs to attend to more families. The advocates' interactions with parents during drop-off and pick-up, or at other school functions, are the primary sources of assessment information for parent/caregiver behavioral health service needs. FAs also conduct at least one home visit per year. (There are plans to increase the number of home visits in the coming program year.)

One full-time family advocate is available for every 18-24 children. Three family advocates are located onsite; two are offsite. All advocates are bilingual and bicultural to ensure that the needs of the families are understood and are met.

Child-Centered Services. A State-mandated developmental assessment is completed for each child at 1 month and at 6-month intervals thereafter. About 15 percent of the children in the CAPS program are referred to the mental health consultant for observation and monitoring but only a few are actually in treatment. Parents are educated during informal visits, home visits, or formal parent education classes concerning developmentally appropriate behaviors, and are trained to engage in activities to encourage the healthy development of their child.

A public health nurse is available to the CAPS staff, providing consultation on health issues, conducting parent education classes, and monitoring child immunizations.

Parent-Focused Services. Services in this program are mostly for mental health needs, domestic violence, and gambling addiction. Family advocates provide a formal eight-session parent education class every Friday evening. About 65 percent of the families attend monthly Parent Club meetings, which include social activities and allow parents to get to know each other.

Wu Yee teachers have primary responsibility for identifying service needs among the target children in the classroom. Family advocates meet weekly with the SESS collaborator, mental health consultant, graduate clinical interns, teaching staff, site supervisors, family service coordinator, and the child development coordinator. Mental health consultants also provide case consultation for special cases requiring clinical intervention.

The Challenges
The addition of family advocates to the preschool staff has been a significant change for Wu Yee preschools. Initial resistance on the part of some teaching staff to the role of family advocates resulted in the departure of several staff members. Now the organizational change is fully supported by the teachers because it allows them more time to work with the children. Wu Yee preschools recently received a Head Start grant. Consequently, CAPS has begun the process of moving to a nationally recognized Head Start model, and it is not clear how this model will affect the design of the CAPS program.

 

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Managed Care Policies Sometimes Prevent Caregivers From Receiving Mental Health Treatment

Under the current managed care admission policy of the public mental health collaborator, parents can be treated for mental health problems only if the treatment is in conjunction with treatment for their child's mental health problem. This is a major constraint for obtaining mental health treatment for the approximately 15 percent of parents who have been identified as needing further assessment and treatment. To get a parent into treatment, the family advocate must refer their child (or perhaps a sibling) who will meet the treatment criteria first.

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Locally Integrated Services In Head Start —Washington, DC

    Program Population

• Latino, African American, African and Other Heritages
• 4—5 Years
• Suburban

    Program Services Include:

• Family Support Meetings
• Home-based Parenting Services
• Social Skills Groups for Children
• Mental Health and Substance Abuse Services

    The Setting
The program was designed and implemented by the Children's National Medical Center (CNMC), a research and service institution located in Washington, DC, focusing on the special needs of children, and collaborating organizations in Montgomery County, MD. The SESS programs are located at half-day Head Start classrooms in five schools in Montgomery County.
 

    The Families Served
The Head Start programs, located in a suburban area, serve neighborhoods with high concentrations of families recently immigrated, typically from Latin American and African nations. Daily contact between families and the classroom is limited by the fact that all children in the Head Start classrooms are bussed to and from school, as well as the logistical problems of transportation in a suburban environment. In attempting to access community-based services, the families typically face barriers of language, social isolation, and reticence to engage institutions because of their status and experience as immigrants.

The Collaboration
The Locally Integrated Services in the Head Start program involve collaboration at several levels. The most intensive collaborative interactions occur within overlapping, interorganizational work groups that carry out the daily activities of the program serving children and their families. These work groups form around major program functions, and their successful collaborative interaction is crucial to the success of the program.

Classroom Work Group. The program provides a classroom consultant trained in early childhood development and psychology to work directly with teachers for 2 hours a week in each program classroom.

Staff Work Group. The SESS intervention staff meets weekly for training, support, clinical consultation, and administrative tasks.

Multidisciplinary Team. A third important program work group meets monthly (at each participating school) to discuss program cases, assess problems, and make decisions about service strategies or referrals. SESS family support and classroom staff, Head Start teachers and Instructional Assistants, and the school psychologist, speech pathologist, and nurse attend these team meetings.

Meetings of the SESS community collaborators also occur on a monthly basis. The formal collaborators group consists of county agency directors or representatives from Family Services Agency, Adult Addiction Services, Adult Mental Health Services, Child Welfare, Infants and Toddlers, Head Start, and Connect for Success, the agency that provides the classroom consultation services. Almost all organizations are regularly represented. The research results from the SESS program will be an important source of information and guidance for reforms in the county.

Engaging in Relationships Through Child- and Family-Centered Services
Families and children are recruited into the full program, including study participation, through announcements and brochures to Head Start parents, through visits by program staff to Head Start functions involving families, and through one- on-one contact. Approximately 10 percent of those who start the intake process decline participation, typically because of busy work and family schedules. The project has enrolled 290 families in 19 classrooms across 10 schools in both treatment and comparison conditions. One hundred and forty of these families participated in the SESS program. Attrition from the project is inevitable because of the transience of the new immigrant population. Approximately 15 percent of the families left the project before completion, often to return to their countries of origin.

Family support workers are para-professionals recruited from the community. They are bilingual and bicultural. Engagement begins with personal contact, establishing a relationship between family support worker and the families. The family support workers' roles are flexible, allowing them to learn from families, and understand the families' needs and goals. This is the family-strength approach that focuses on the whole family rather than focusing narrowly on family eligibility for an established list of services.

Child-Centered Services. Children receive basic program services through membership in a selected classroom. These services include a curriculum that promotes positive social-emotional and behavioral development. In addition, the SESS program has initiated several social skills groups that meet daily for 2 weeks in the summer and serve approximately 20 percent of the program children identified as higher need for social skills development.

Family-Centered Services. The personal and culturally appropriate linkages to the program appear effective in promoting participation, as does the fact that services are offered in families' homes.
 

• Family-Strengthening. The program features a multifaceted program of parenting education support. Home visits focus on important parenting issues including parent-child interactions, discipline, and appropriate ways to set limits for children. SESS also teaches parents to better connect with their children through play and other daily interactions. The family support meetings include family social and educational time, and a support group discussion in which caregivers raise issues of concern. Educational meetings on particular parenting and family topics are also organized.
• Caregiver Behavioral Health. The program offers a holistic approach to caregivers' mental health and substance abuse needs based on the relationship between the family support worker and the family. The clinical coordinator can also offer assistance when appropriate.
• Fundamental Needs. The family support workers' family-centered case management style focuses on getting to know families within their daily context. Family support workers offer assistance for a broad range of needs including clothing, transportation, food, housing, positive recreation, transportation, English language skills, and other issues that caregivers must meet on a daily basis.

    The Challenges
Despite this institutional interest in collaboration, services frequently needed by the SESS families are in short supply and are often not easy to locate or access. Resource limitations and established service emphases limit the degree to which Head Start serves some needs central to these families, and changes in publicly funded services have curtailed access to child mental health services. Spanish-language services are also in short supply, and the system of service for many of the basic needs of these families is fragmented and changing. These characteristics of the service environment provide a challenge to the SESS program.

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Barriers That Keep Families From Participating

• Convenient, Accessible, and Affordable Transportation
• Language
• Social Isolation
• Fear of Engagement with Government Institutions Due to Immigrant Status

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Starting Early Starting Smart Head Start Collaboration Project —Illinois

Program Population:

• African American
• 3—4 Years
• Urban

Program Services Include:

• Primary Health Care Services
• Prenatal Care
• Mental Health and Substance Abuse-Related Services
• Effective Black Parenting, a Parenting Skills Program

    The Setting
The Women's Treatment Center (TWTC), in collaboration with the Ounce of Prevention Fund of South Side Chicago, is providing integrated behavioral health services in the St. Paul Head Start and Garfield Head Start programs. TWTC provides inpatient and outpatient substance abuse treatment services to women with children. Services include a recovery home residential unit in which women and children can reside up to a year while pursuing employment or education goals. Ounce of Prevention is a nonprofit agency that operates Head Start centers and a multipurpose community center.

The Women's Treatment Center, Ounce of Prevention, and the University of Chicago are evaluating the results of providing behavioral health services at selected Head Start programs, comparing those families to families at another Head Start program who are not offered the extra services.

 

    The Families Served
Most of the families TWTC serves live in the Robert Taylor public housing complex in South Side Chicago. The entire population of the St. Paul Head Start and Garfield Head Start programs, where the SESS programs are offered, are African American. The children and their families at CHASI/Englewood Head Start are also African American and serve as the comparison group for the evaluation study.

Originally, the Garfield Head Start program was not included in the SESS program, and it became difficult to enroll families in the program when the Department of Housing and Urban Development (DHUD) closed three of the housing units in late 1998 and 1999 in preparation for demolition. Many residents were moved, so TWTC added Garfield as an intervention site and selected CHASI/Englewood to serve as the comparison site.

The only specific criteria for inclusion in the SESS program is income level, which mirrors the Federal guidelines established for participation in Head Start programs. When caregivers volunteer to participate in the baseline/intake interview, their child or children are automatically enrolled in the SESS program. Services are available at the Head Start programs for non-SESS children and families, with the exception of those provided by the psychologist and the parent-child specialist.

The Collaboration
TWTC has memoranda of agreement with Ounce of Prevention and the Hayes Center Public Health Clinic. Other organizations involved in the SESS program, with which there are no formal memoranda of agreement, include: Englewood Family Health Centers, the Center for Successful Childhood Development (CSCD), the Chicago Department of Public Health, Catholic Charities, La Rabida Children's Hospital and Research Center, and the Grand Boulevard Federation. SESS has offices in the multipurpose Charles A. Hayes Family Health Centers and in another Ounce of Prevention services building located in the community.

The heart of what makes the collaboration between organizations work are the regularly scheduled team meetings. A project team addresses program and policy issues, the status of systems/services integration, and any internal or external problems that may arise. The multidisciplinary team meets monthly to discuss the progress and needs of the children and their families. The SESS program staff members are in almost daily contact through meetings and informal contacts with Garfield and St. Paul Head Start center staff and with their collaborating agencies to discuss resources, services, and other program issues.

Also critical is the SESS-conducted cross-training of both public and private agency personnel who work on the project and staff of agencies serving the SESS families. For example, SESS staff conducted a 2-session, 8-hour training for Ounce of Prevention staff and for staff representing 15 community-based agencies. Since the initiation of the grant, more than 50 individuals have received training of 6 hours' duration on average.

Engaging in Relationships Through Child- and Family-Centered Services
The SESS team providing services at the Head Start programs includes the project director, two substance abuse/family support counselors, a consulting psychologist, and a parent-child specialist. The substance abuse/family support counselors are not fully integrated into the Head Start staff. The psychologist and parent-child specialist work with families wanting assistance and serve as a resource to the Head Start staff.

Family-Centered Services. SESS offers services in the early morning and evening hours so that working parents can participate regularly. Staff also meet with families in non-traditional community settings and informally onsite. SESS uses the Effective Black Parenting program to improve parenting skills and to engage families. In addition to the more common Head Start parenting skills and strengthening groups, the SESS programs have parent participation committees and offer unique programs for parents, including cultural programs and individual assistance to strengthen particular parenting skills. The family support specialist coordinates case management services for the Head Start families by preparing plans and agreements in partnership with the families, which are reviewed and updated regularly. The mental health clinician participates in the case management of each family and assists in gathering information and making decisions about each family's needs.

Families who need primary health services are referred to the primary health clinic located at the Hayes Center, several blocks from the Head Start sites. The clinic, operated by the Chicago Health Department, is staffed with a nurse practitioner and medical assistant. Prenatal care and other services are referred to affiliated public facilities and private facilities that accept Medicaid. Adult family members are referred to mental health and substance abuse- related services. These services are used by approximately 25 percent of the participants.

Child-Centered Services. All Head Start children are required to have received primary care screening prior to admission and are referred for medical examinations, ongoing health care needs, and dental, vision, and hearing services as necessary. In addition, families can visit the primary health care clinic located in the Ounce of Prevention's Hayes Center. SESS children are also screened for mental health needs through formal testing, team/case management judgment, observations, and monitoring.

While no mental health services are specifically provided through SESS, the mental health counselor, SESS staff, and training of Head Start staff provide increased ability to identify and coordinate mental health service needs. The consulting mental health clinician works with families to decide whether or not any family member will receive mental health or substance abuse services. The comparison sites have a part-time mental health consultant who visits the program approximately 10 hours per week and meets with Head Start staff. This role is primarily to assist Head Start staff in identifying children (and to a lesser extent their caregivers, given time constraints) with mental health service needs and to make suggestions regarding referrals.

SESS has worked with Ounce of Prevention to plan health education programs, in addition to those already offered by the Head Start centers and the Hayes Center health clinic. Printed health education materials regarding prenatal care, HIV/AIDS, substance abuse, STDs, and other health problems are also available at the Head Start centers and at the Hayes Center.

The Challenges
While public housing demolition caused SESS to experience a decrease in the prospective participant pool, the staff revised and intensified their recruitment efforts, increased the bonus for bringing a friend to the program, and reached children and parents in other housing developments. The complicated family lives and demands on the family time makes it challenging for SESS staff to meet with parents and involve them in the research and services. Families often don't have telephones, which makes communication more difficult. Other program problems include staff concerns about not having enough time to meet and not having enough experienced personnel. Staff members especially want more time from the mental health consultant and the family support supervisor. Filling job vacancies has also been difficult because of the low salaries offered.

Epilogue
A series of events transpired [which have made it necessary for the Illinois site to withdraw from the SESS study before its completion]. The following recitation of the factors involved illustrates vividly the dynamics faced by many communities and families:

1. Changes in welfare reform, which required that mothers go to work, also changed the focus of the SESS women participants' lives and limited their availability for participation in Head Start/ SESS activities during the day.
2. The attendance in half-day Head Start began to decrease as the demand for full-day Head Start increased to meet the mother's requirement for childcare in order to work.
3. Ounce of Prevention was reorganized and a decision was made to change the focus for staff training and development.
4. Building and startup of the new Ounce of Prevention Educare Center.
5. Constant gang warfare plagued the public housing complex to such an extent that there were many days the families would not leave their apartments.
6. The decision and subsequent action of the Chicago Housing Authority to begin demolition on some of the buildings in the public housing complex led to the relocation out of the neighborhood of many Head Start families.

In response to these events, TWTC, after consultation with the Ounce of Prevention Fund decided to continue staff training around substance abuse issues and working with families, but to discontinue direct services to the families. TWTC decided to shift the direct services to another Head Start site in a neighboring community, which had participated in the community consortium trainings that TWTC presented. The Abraham Lincoln Head Start programs were very interested in receiving services for their parents. This new Head Start site has worked out well and supports the concept that collaboration between early childhood and substance abuse programs can work.

Behavioral Enhancement Through Training and Treatment To Expand Resiliency (BETTER) —Maryland

Program Population:

• African American
• 3 - 5 Years
• Urban

Program Services Include:

• Cultural Specific Parenting Curricula and Parent/Family Activities
• Parent Education Curricula, Such as the Pyramid to Success (Effective Black Parenting)
• Developing New Parenting and Child Behavior Management Skills
• Families and Schools Together (FAST) Program

    The Setting
Project BETTER, administered and evaluated by the Johns Hopkins University (JHU) School of Hygiene and Public Health, provides behavioral health services that are integrated into the ongoing activities of two Head Start Centers in Baltimore located in African American communities. BETTER provides onsite mental health services for children and their caregivers, as well as parenting and other prevention services. SESS mental health clinicians at the Head Start centers support Head Start case management activities by identifying and working with public and private sector social, health, and mental health agencies.

The Families Served
The two Head Start centers serve children 3 to 5 years old. Johns Hopkins University BETTER project services are available to all enrolled Head Start children and their families. The two Head Start centers have a structured educational curriculum and onsite strategies for assessing and meeting multiple family and child needs. BETTER contributes to these efforts and provides a range of services that children and families would not ordinarily receive. Head Start provides physical and developmental assessments of the child and newly enrolled families are assigned a case manager. The family services coordinator works with the family to assess service needs and develop an individualized service plan for meeting these needs.

Three SESS staff members deliver and coordinate SESS program services: the full-time, onsite, mental health clinician, the half-time family community resource coordinator, and the half-time parent liaison/administrative assistant. Approximately 50 to 74 percent of children served through the SESS program receive specialized assistance through their participation in the program.

The Collaboration
JHU works with State, local, and neighborhood public and private sector agencies, which provide early childhood development services and physical and mental health services. The organizations with which project BETTER is collaborating (in addition to the Head Start intervention and comparison sites) include the following: Baltimore Substance Abuse Systems provides assistance to SESS in locating substance abuse treatment services; Family League of Baltimore City is a city management board that coordinates the integration of services for children 0-6 and their families.

Kennedy Krieger Institute, whose developmental pediatrician, Dr. Harolyn Belcher, is a co-investigator on the SESS project, provides consultations to the Head Start centers and helps coordinate services through Kennedy Krieger when appropriate. Finally, the Baltimore Mental Health Services coordinates citywide mental health services and initiatives.

The long-standing history of collaboration engaged in by various departments and staff of JHU greatly facilitated the process of services integration in Project BETTER during the second year of the project. The collaborating organizations were closely involved in the planning process for the project, meeting once or twice a month in the first five months of the development and implementation of the program. The collaborating agencies discuss all issues related to the project, including logistical problems, resource availability and constraints, services to be provided, and strategies for further developing agency linkages.

Onsite services are coordinated for children and families within the Head Start setting. A case management team, which includes the family, meets monthly to develop and then review family plans, making referrals for specific problems and services as needed. Informal meetings of appropriate staff are arranged to address particular needs or issues of the children. The SESS family community resource coordinator and mental health clinician can also participate in family planning meetings and help bring additional services to families if they want them.

Engaging in Relationships Through Child- and Family-Centered Services
SESS uses several strategies for engaging families. SESS staff work with family or caregivers to learn about the family"s overall needs and goals. SESS staff provide a culturally specific parenting curricula and parent/family activities. Parent education curricula, such as the Pyramid to Success (Effective Black Parenting), promote pride in the African American culture, while strengthening family relations and developing new parenting and child behavior management skills. In addition, the Families and Schools Together (FAST) program is a family-centered group designed to strengthen family roles, promote positive parent- child communication and discipline, provide substance abuse prevention, and empower parents to act as advocates for their child and family.

Through SESS, children are provided initial and ongoing screening for mental health needs through formal testing, team/case management observations, and monitoring assessments. Referrals for services are made as necessary by the mental health clinician in partnership with the family. SESS onsite clinical services include assessments of behavioral and/or socialization issues; referrals for psychological testing as necessary; and play therapy for aggressive or violent behavior, grief issues, exposure to substance abuse inutero, or family/anxiety stress.

SESS staff members also help families and caregivers get health insurance coverage (if not currently covered) and find eligible service providers; understand their strengths and find solutions to their problems; make decisions about program services and implementation; and address their basic physical needs. Project BETTER offers services such as home visits in the evening and at other times that are convenient for the families. Developmental services for children are also provided at flexible times. Despite these strategies, JHU has still found that transportation and child care issues are major barriers to family utilization of services while language issues are minor challenges.

Child-Centered Services. All of the Head Start children are required to have received primary care screening prior to admission. While in the program, the children are referred for medical examinations, with ongoing provision for health care needs and for dental, vision, and hearing services as necessary. One site sponsors an annual health fair, where screening for children and their caregivers is available.

Family-Centered Services. Mental health and substance abuse services are available to 100 percent of children and adult family members through the SESS program. SESS offers occasional prevention and educational activities for substance abuse in particular. The full-time mental health clinician identifies needs and provides services (onsite or referral, as necessary) for caregivers and provides additional services for children.

The Challenges
One challenge affecting this program is a reduction in anticipated SESS funding. Service provision has been maintained because of extra efforts and persistence on the part of staff. Another challenge is the mobility of parents who move in and out of the neighborhoods and who simply drop out of the program.

New Wish —Nevada

Program Population:

• African American and Hispanic
• 3 - 5 Years
• Urban

Program Services Include:

• Parent-Child Activities
• Mental Health Assessment and Intervention for Children
• Service Coordination for Behavioral Health Services
• Short-Term Family Counseling
• Family Classes About Issues Such as Financial Planning, Nutrition, and Stress Reduction
• Development Skills Building in Classrooms for the Children

    The Setting
New Wish, the Starting Early Starting Smart program, is operated by the State of Nevada, Division of Child and Family Services/Early Childhood Services. Early Childhood Services provides public sector mental health, family preservation, and developmental services to children up to the age of 6 and their families. New Wish offers their services at five of the Clark County Economic Opportunity Board-s 13 Head Start sites, which serve children between the ages of 3 and 5. New Wish operates in Las Vegas in Clark County, where the population has ballooned by 42 percent from 1990 to 1996. The county social and health services system is straining to meet the needs of this new population.

The Families Served
New Wish interventions are available at five Head Start sites, serving about 52 percent or a little more than 660 children enrolled in regular Head Start programs. The children are African American and Hispanic. All New Wish services are available to every family whose child is enrolled in Head Start at an intervention site. A subgroup of these families is the subject of research for Starting Early Starting Smart.

The Collaboration
One purpose of the New Wish project is to enhance the Head Start programs by offering children and families prevention programming, staff consultation, and training. Another purpose is to work with Head Start staff to engage with families who could benefit from behavioral health interventions and families with mental health, substance abuse, and domestic violence issues. These children and families may engage in brief therapy with New Wish staff, and may be referred with support to other appropriate agencies for specific treatment needs.

The current SESS collaboration builds on past interagency efforts to serve Head Start families. The three primary partners are DCFS/Early Childhood Services, EOB Head Start, and Nevada Parents Educating Parents (PEP), a private, nonprofit, independent family advocacy agency. A community steering committee includes other collaborators with similar interests: Clark County School District, Community College of Southern Nevada (which has an associate degree program in early childhood education), the Bureau of Alcohol and Drug Abuse, Southern Nevada Adult Mental Health Services, Safe Nest (domestic violence program), Boys and Girls Clubs, and Clark County Social Services.

Engaging in Relationships Through Child- and Family-Centered Services
New Wish provides four onsite behavioral health specialists to the Head Start programs. Parents can obtain information and educational materials about family issues, check out toys and activities with a parent-child relationship focus, and establish relationships with New Wish staff to talk about specific family issues.

New Wish staff supports and trains the Head Start staff. Counselors provide ongoing support groups and topical discussions with Head Start staff as requested. They assist Head Start staff in identifying children with developmental and behavioral health needs and making appropriate referrals for them. They also work with family service workers to develop parent-child relationship building activities for Parent Center Meetings.

New Wish staff provides classroom activities for all intervention classrooms. These activities are designed to promote the children's healthy psychosocial development. They include topics such as verbal expression of feelings, verbal problem solving, social skills, and coping mechanisms for handling stress. Teachers are also encouraged to incorporate similar supportive activities into their curriculum.

A variety of prevention activities are available to parents and families. These activities are important for establishing a trusting relationship with Head Start families and to give families the opportunity to address their needs. Topics are wide-ranging, and include parenting issues, advocating for children, improving parent-child relationships, financial planning, nutrition, stress management, family relationships, and household management. Ongoing parent support groups are also provided at the intervention sites.

New Wish counselors also engage in short-term therapy with families. The service can be accessed informally and on an as-needed basis. Counselors provide some case management and facilitate referrals to other agencies for more extensive services when warranted. If parents wish, they may facilitate establishment of an interdisciplinary team of representatives of involved agencies to meet periodically with the parents to establish and maintain an overall treatment plan. These meetings may include Head Start family service workers and may take place at the family home or at the Head Start center, as the family wishes.

The Challenges
New Wish and Head Start have found that parents and caregivers sometimes disagree with professional assessment that their child needs referral for a developmental or mental health issue. Parents sometimes take this information as criticism of their child-raising practices and some parents, particularly new immigrant families, feel ashamed because they have been singled out. Parents are sensitive to language or phrases that may have a negative stigma (such as 'special needs') and do not typically differentiate between preventive and intervention services. Additionally, some parents are reluctant to share their personal concerns and information about their home life with others. The multidisciplinary teams are threatening to many parents, who prefer to work with service providers one-on-one.

Treatment teams have been difficult to pull together, although progress is being made. Service providers are busy and tend to view the time it takes to coordinate services as extra work that is added to an already demanding work schedule. Selective training about confidentiality has been provided for staff at some intervention sites, and different confidentiality standards have been discussed and reviewed by the New Wish steering committee.

Most parents are receptive to parent support groups, where participation is high and the feedback is positive. Families typically access New Wish counselors informally, on an as-needed basis, more in line with how they might use a primary health care professional. Most families have viewed this pattern of use of services as helpful. It may be an alternative approach to services provision that is more compatible than the traditional model for integration of services into community settings.

 

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Christa's Story
Christa's mother met with a New Wish counselor because of her husband's history of domestic violence and drug use. She reported that her children had witnessed several incidents of violence against her, and she was worried about the affect it was having on Christa. She obtained a protective order against her husband, but was concerned about Christa's drastic mood swings and noncompliant behavior. The New Wish counselor worked with the whole family to learn about ways to handle domestic violence and substance abuse. They also worked together to build self-esteem and to help develop new parenting skills for the mother. Over time, Christa developed a positive self-concept by learning to establish eye contact with people. Christa was also helped with her speech delays and she learned to verbalize her feelings, which also helped build her self-esteem.

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Elijah's Story
Elijah's mother and father became concerned about his inability to sleep, his hyperactivity, and his temper. Elijah was physically aggressive towards his 5-month old sibling and would throw his toys when he was angry. His father thought that Elijah needed medication to control his behavior. The parents met with New Wish counselors to talk about their concerns. The New Wish counselor met with the family to learn new parenting skills and ways to help Elijah adjust to his new sibling. After working with Elijah and his family, there was no need to medicate Elijah.

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Primary Health Care Sites

Miami's Families: Starting Early Starting Smart —Florida

PROGRAM POPULATION:

· African American, Hispanic, and Caribbean Islander

· 0 - 3 Years

· Urban

PROGRAM SERVICES INCLUDE:

 · Family-Driven Care Coordination
· Multidisciplinary Intervention Team
· Clinical Evaluation of Caregiver Substance Use/Mental Health
· Substance Abuse/Mental Health Treatment Engagement
· Short-Term Individual and Family Counseling and Crisis Intervention
· Preventive Educational Topic Groups Related to Mental Health and Substance Abuse Prevention
· Therapeutic Baby & Me Bonding Groups
· Strengthening Multi-Ethnic Families and Communities Program (by Marilyn L. Steele, Ph.D.)
· Grandmothers' Support Group
· Parent Advocacy Group

    The Setting
Miami's Families SESS is administered by the University of Miami (UM) School of Medicine's Perinatal Chemical Addiction Research and Education (CARE) Program. This primary care site is based at the Juanita Mann Health Center (JMHC), a UM/Public Health Trust Community Health Center, which provides a full array of primary health care services to residents of Liberty City and surrounding areas. These neighborhoods have been shown to be some of the hardest hit by poverty, drugs, and crime, including domestic violence and child maltreatment, in Miami-Dade County. WIC and Medicaid offices are co-located within the JMHC, and the clinic is in the same shopping center with several other social service agencies. A SESS social worker, mental health counselor, and two care coordinators are onsite at the JMHC, where offices and shared classroom space are used to provide groups, individual counseling, and advocacy services. Shared space is also utilized at the JMHC by the SESS coordinator, two developmental therapists, and driver. The SESS evaluation clinic is located at the UM medical campus, conveniently accessible to the neighborhoods served.

The Families Served
Currently, 121 families participate in the SESS Services Integration approach, with another 121 followed as a comparison group receiving standard community services. Caregivers of newborns (0-2 months) were screened for substance abuse, mental health, and parenting risk factors, and at-risk families were offered SESS enrollment. Referrals were received from the JMHC staff, the Jackson Medical Center's Prenatal Substance Abuse Clinic and Labor and Delivery admissions, the Department of Children and Families, the court system, and other collaborating agencies. Fifty-three percent of participating caregivers were identified as substance users at enrollment. Current SESS participants are ethnically diverse, including 52 percent African American, 29 percent Hispanic, 12 percent Caribbean Islander, and 7 percent Caucasian families. All SESS services are offered in English and Spanish.

The Collaboration
The Perinatal CARE Program collaborates with a wide variety of community organizations that provide direct health care, substance abuse treatment/prevention, adult and child mental health, and basic needs services. The JMHC medical staff and Healthy Start High-Risk Children's Program community health nurses are fully integrated into the SESS Multidisciplinary Team. Collaboration with The Village and other substance abuse treatment providers has consisted of prioritized referral processes and ongoing consultation with treatment center staff to monitor and support client progress. Simplified referral and co-staffing procedures have been established with the Children's Psychiatric Center and several adult mental health providers. Streamlined referral and service access with early intervention providers has ensured that children identified as developmentally delayed receive immediate evaluation and placement. SESS program staff provide cross training to collaborators, as well as in-kind parenting services to non-SESS families residing at The Village or referred by the courts or Children and Families.

Involvement in various local human services coalitions has been extensive. Through such efforts, SESS has been successful at persuading various community stakeholders to invest in Service Integration. The Miami-Dade County Health Department and Healthy Start Program have directly funded care coordination and clinical service staff. The Health Foundation of South Florida has also supported SESS care coordination and evaluation efforts, and funding for parenting services has been contributed by the United Way of Miami-Dade and the Miami-Dade County Department of Human Services.

Engaging in Relationships With Families Through Family-Centered Services
Care Coordination. Care coordinators, supported by a multidisciplinary team, provide intensive services in a flexible, family-centered format to maintain rapport and facilitate family participation in interventions. Activities include regular face-to-face contact at home visits and onsite at the JMHC; appointment scheduling, reminders, and follow-up; ongoing needs assessment and participatory family service planning; facilitation of needed service referrals (including basic needs) through cross-agency contacts; and ongoing referral follow-up to assess and address barriers to service utilization.

    Mental Health and Substance Abuse Treatment and Prevention. Training for all levels of SESS and collaborating agency staff in the areas of substance abuse and mental health is essential to properly serving families affected by these issues. Ongoing clinical evaluation and informal observation of caregivers" substance use and mental health status is equally important, since these are dynamic factors. SESS staff utilize a flexible approach, addressing these issues with caregivers at their current level of readiness for change. Crisis intervention and stabilization services are often needed, and treatment engagement efforts are intensive when a need for formal treatment is identified. These engagement activities attempt to overcome treatment barriers through ongoing discussion and supportive encouragement by all SESS staff, solicitation of the support of family members and significant others, and a focusing on the impact of parental functioning on children and families. When formal referrals are unwanted or not necessary, short-term individual and family counseling sessions are provided by licensed SESS staff. Preventive educational topic groups related to mental health and substance abuse prevention have been offered monthly on various requested topics.

 

    Parenting Interventions. Several group and individual services have been designed to support successful parenting of infants and young children, and efforts are made to include all significant caregivers mothers, fathers, extended family, and alternate caregivers. Interventions encourage the development and maintenance of positive and appropriate family and peer support systems. Families find it helpful that individual and home- based parenting sessions are available when issues cannot be appropriately addressed in a group setting or they are unable to attend. Various non- monetary incentives are used to maintain participation in parenting activities, such as small topic-related gifts, meals, and transportation. Formal group curriculums include therapeutic Baby & Me bonding groups and the Strengthening Multi-Ethnic Families and Communities Program (created by M.L. Steele), and families participate in a formal graduation ceremony following completion of each group. In addition, an ongoing Grandparents' Support Group and Parent Advocacy Group meet regularly.

The therapeutic Baby & Me group is a 14-week parent-infant therapy aimed at the promotion of attachment, caregiver knowledge and understanding of infant development and behavior, and empowerment/insight into the impact of the caregiving environment. Each session with three to five parent-infant dyads is 21/ hours and includes group process activities, structured parent- child interaction, practical didactic discussions, and work on a baby book. Didactic topics include attachment, infant communication cues, crying/soothing, sleep/wake patterns, infant medical care, feeding, safety, child abuse prevention, stress management, and anticipatory developmental guidance. Sessions are designed to facilitate discussion in a manner that is fun and engaging, as well as educational.

The 14-week Strengthening Multi-Ethnic Families and Communities Program meets 3 hours weekly with 10-12 parents. The emphasis is on assisting parents to raise children in a violence-free environment. Violence prevention is addressed within the perspectives of ethnic/cultural roots, parent-child relationships, parent modeling in the family and community, and parent teaching and discipline. The curriculum helps parents teach children to express emotions, develop empathy, manage anger, and enhance life skills needed to function in today"s society. The program also integrates positive discipline approaches aimed at fostering self-esteem, self- discipline, and social competence. Developing cultural awareness through family rituals/traditions and the importance of community involvement by parents are emphasized.

The Challenges
The greatest challenge in carrying out the SESS project is the constant struggle to balance the allocation of limited time and energy among monitoring and preserving service delivery fidelity, maintaining ongoing collaborative relationships, providing appropriate staff training and supervision, and pursuing various sustainability activities to keep the program funded. Of course, there have been various challenges within each of these areas. For example, high-risk families often have multiple demands on their time, including work and treatment schedules, and sometimes frequent moves make it difficult to even locate participants. However, the Perinatal CARE Program has many well-developed methods of addressing and facilitating family retention and engagement. We have found that at all levels of interaction with families, staff, other agencies, and funders, trust- building through good working relationships is central to the success of SESS Service Integration.

Raising Infants in Secure Environments (R.I.S.E.) —Massachusetts

Program Population:

• African, African American, Hispanic, Haitian, and Caucasian
• 0 - 2 Years
• Urban

    Program Services Include:

• Ongoing Case Management and Care Coordination
• Parenting and Family Strengthening Classes
• Employment and Career Services
• Family Support Groups
• Family Recreation and Enrichment Programs

    The Setting
Project R.I.S.E. (Raising Infants in Secure Environments), housed at Boston Medical Center (BMC), is for families receiving primary care services at the BMC pediatric outpatient department. Central to the design of Project R.I.S.E. is a focus on increased access to behavioral health services within the hospital setting. Project R.I.S.E. provides most essential services for newborns and their caregivers within the medical center, referring clients externally only to State and city agencies for substance abuse treatment and to public and private sector agencies for social services including housing.

The Families Served
The families and children served by Project R.I.S.E. are parents who seek services at the BMC primary care clinic, the newborn nursery, and the Family Practice Clinic. Project R.I.S.E. is based on and continues from the Healthy Steps model of pediatric care. Project R.IS.E. is particularly interested in initiating service for those children under the age of 3 months who are not HIV positive. Mothers of newborns and any number of children are eligible to participate in Project R.I.S.E. Also included are infants greater than 34 (as opposed to 35) weeks of gestation. The BMC pediatric primary care clinic serves Haitian, Nigerian, African American, and Latino families.
 

The Collaboration
In addition to improving internal collaboration between departments in a large, university-affiliated medical center, Project R.I.S.E managers involved external agencies where they have long-standing relations. Clearly defined roles and responsibilities and coordination with multiple units and facilities are fundamentally important to the success of this effort.

The multidisciplinary team meets weekly to review cases and to coordinate referrals to onsite and external SESS collaborators. The Project R.I.S.E. team works to build strong community relationships by serving on a number of advisory boards and ongoing work groups, and by attending meetings of other coalitions in the Boston area. The collaboration is further strengthened through written updates and information sharing.

The two boards, the Senior Board and the Monthly Advisory Board, help manage the program. The Senior Board, the senior management body of Project R.I.S.E, meets annually to address program policy and service issues and to troubleshoot internal or external problems. The Monthly Advisory Board, the mid-level supervisory group for the project, addresses policy and services, handles external and internal problems, coordinates service schedules, and then tracks the status of systems and services integration efforts.

Engaging in Relationships Through Child- and Family-Centered Services
SESS has enabled Project R.I.S.E. to provide comprehensive and enhanced primary care for the newborns and their families, coordinating and facilitating access to health services available at this large medical center. All of the participants use primary pediatric care services.

Family Advocates are the essential element in engaging and partnering with families. Advocates and family members prepare the comprehensive clinical intake assessment during in-home and clinical visits and work with family members to develop a case management plan, which is reviewed weekly. SESS Advocates provide each family with information and referral for services within and external to BMC, as well as accessing services whether or not directly part of Project R.I.S.E.

Additionally, involving African American, Latino, or Haitian advocates and interviewers, as well as meeting with families in nontraditional settings, has proved beneficial in building a trusting relationship between staff and the family. Project R.I.S.E has found that building on the family cultural strengths helps to engage and maintain family- staff relationships.

 

Having worked at the hospital, I thought I knew where to go for children's health and developmental services. Yet when I took over the care of my sister's children, I found I didn't know where to go for the services they needed. Project R.I.S.E. helped me find what I needed for my children." -Caregiver of children in Project R.I.S.E.

The SESS project provides several services for strengthening families. These include parenting and family strengthening classes, employment and career services, family support groups, and family recreation and enrichment. Project R.I.S.E. also works with family members to identify appropriate approaches to meet caregiver and family needs.

Currently, 25 to 75 percent of the participant caregivers receive mental health and/or substance abuse services. In these cases, behavioral health staff may work with clinical specialists and the families to evaluate the need for and provide acute short-term treatment. The behavioral health staff also makes referrals for services as necessary with State and local agencies and private nonprofit service organizations.

 

Family Advocates use various approaches to engage families by: ensuring continuity of relationship between clients and advocates; meeting basic needs whenever possible (housing, entitlements, food, daycare and summer camps for siblings); and facilitating access to information regarding immigration issues.

The Challenges
The project has encountered and addressed several issues related to enrollment. One problem the project encountered when working to engage families was that welfare reforms resulted in many women returning to work and not having the time to participate in the program. When the hospital established the Family Practice Clinic, which provides pre- and post- partum and pediatric primary care, referrals to the program decreased. Project R.I.S.E. staff met with the director of the Family Practice Clinic to expand the project to work with Family Practice Providers caring for families who meet Project R.I.S.E. criteria. Project R.I.S.E. also expanded its eligibility requirements to enable it to recruit Haitian Creole speaking families.

Healthy Foundations for Families —Missouri

Program Population:

• Caucasian, Multicultural, and International Population
• 0 - 5 Years
• Urban

Program Services Include:

• Family Support Groups
• Family Workshops on Kindergarten Readiness, Conflict Resolution, Disciplinary Approaches
• Holistic Approach to Family Needs Including Housing, Transportation, Recreation and Others

    The Setting
The Missouri Institute for Mental Health, affiliated with the University of Missouri-Columbia School of Medicine and based in St. Louis, has a small satellite office in Columbia that operates the Healthy Foundations for Families (HFF) program. HFF recruited from three Boone County primary health care clinics, which referred families with children from birth to 5 years old who indicated an interest in the SESS program.

The Families Served
HFF services are available to families attending participating primary care clinics that consent to take part in the program. These families must have a child between the ages of birth and 5 years and reside in Boone County to be eligible. To date, the program has enrolled 78 families as program participants, with 71 families serving as controls. The population is a mix of Caucasians, minorities, and immigrants.

The Collaboration
Healthy Foundations for Families collaborates with several Boone County agencies to facilitate service delivery for families. The program also worked with the Mid-Missouri Mental Health Center, the Family Resource System, the Private Industry Council and the Boone County Group Home, the Division of Family Services, the Parents as Teachers Program, and the Department of Pediatrics with the University of Missouri-Columbia. These agencies are generally consulted on an as-needed basis for specific families and some of them work with Healthy Foundations for Families on joint parenting projects. Several of these collaborators contributed significantly to program staff training.

The staffing for the project reflects the program's heavy emphasis on research. Program staff includes a co-principal investigator/evaluator from Missouri Institute for Mental Health, a co-principal investigator from one of the primary care clinics, a clinical consultant, a project director, three case managers (equivalent of 2 ^1/2 full-time employees), and support staff. Research staff includes a data coordinator, three psychology technicians responsible for administering all testing instruments to families in the research project, two testing/ video assistants, and a testing consultant.

Engaging in Relationships Through Child- and Family-Centered Services
Healthy Foundations for Families provides case management, parental support and information, and other needed services. SESS program staff, located in the primary health care clinics, provide immediate screening and assessment of families who indicate their interest in the program. After initial screening, assessment, and assignment to treatment or control conditions, program staff arrange appointments with treatment families offsite or in the family's home as determined by the family. From this point forward, families work with project staff and other referral agencies at various locations identified and selected by the families, including their home. Families can participate in the program for 18 months.

Healthy Foundations for Families primarily focuses on family services and parenting through a referral- based case management program. Case managers, known as family associates, develop individualized service plans with each family to meet their family's unique needs. Services vary widely based on each family's needs. The service plan considers family needs and strengths around the following issues to achieve identified goals in these areas:

• housing/food/clothing
• transportation
• financial/insurance
• health/safety
• legal
• vocational/educational
• family/intimacy/
• leisure time/talents/spirituality cultural experiences
• social supports/skills
• parenting/child-rearing

    In addition to case management services, the program also provides regular parenting workshops and support groups for families. Workshop subjects have included kindergarten readiness, conflict resolution, choosing a preschool, and disciplinary approaches for parents. Periodic newsletters with parenting information are distributed to participating families. Parents in the program assist with the programming on a volunteer basis. The program does not directly deliver services in physical or mental health or substance abuse treatment. Focus groups with families have indicated that the strength of this program lies in its one-on-one relationship between case managers and families.

The Challenges
The program has been very successful in forming strong collaborative relationships with local health care clinics and physicians despite a slow start-up. Several factors contributed to initially slow referrals including (1) strict Institutional Review Board requirements that prohibited program staff from recruiting families directly; (2) clinic doctors' lack of knowledge and training regarding mental health issues (including hesitancy to address mental health issues with patients); and (3) some doctors' reluctance to refer families to the program because the research design did not include a comparison group, which meant that some families would not receive the SESS program services. However, with considerable work by both clinic and program staff, recruitment increased and program enrollment has reached its original projections.

Funding of two almost identical programs in one small county deterred Healthy Foundations for Families from creating a system-wide collaboration. After initial problems, the two programs joined with one agency to work on parenting programming for families from both grants. Despite significant first- year problems, including complete staff turnover, Healthy Foundations for Families is now successfully serving families and working collaboratively with local agencies, which appears to be the result of very strong and dedicated new project personnel.

Starting Early to Link Enhanced Comprenhensive Treatment Teams (SELECTT) —New Mexico

    Program Population:
Populations in the city of Albuquerque are distributed across the major ethnic groups. This is reflected in those enrolled in the SELECTT program.

• Hispanic
• Anglo
• African American
• American Indian
• Multiracial
• Birth - 3 Years, with Continuing Service Up to 7 Years
• Urban, Suburban, and Rural Regions of Albuquerque's Metropolitan Area

    Program Services Include:

• Primary, Coordinated Medical Care
• Case Management Services
• Child Developmental Assessment and Intervention
• Legal Services
• Solution Focused Clinical Approaches
• Substance Use Counseling
• Mental Health Counseling for Children and Adults
• Parenting Support Groups
• Interdisciplinary Team Services
• Parent Advisory and Community Steering Advisory Committees
• Extensive Community Referral Base to Early Intervention, Behavioral Health Services

    The Setting
The University of New Mexico's Health Sciences Center (HSC) in Albuquerque is the site for the Starting Early to Link Enhanced Comprehensive Treatment Teams (SELECTT) program for families and their children. The University's School of Medicine and University Hospital are part of the University of New Mexico's Health Sciences Center (HSC). Families from the State of New Mexico are offered comprehensive primary and behavioral health care through the HSC clinics. For the purposes of this study, however, only families residing in the greater metropolitan area of Albuquerque, within a 40-mile radius, will participate in SELECTT.

The Families Served
The program enrolls children under 3, with continuing services to age 7, when there is identified family substance use, mental health problems, domestic violence, or unsupported teen issues. Siblings are also served by SELECTT, sometimes receiving more SELECTT services than the target child because they had not previously received the wide spectrum of special services SELECTT provides. The unique feature of the program is its capacity to address the needs of the entire family, focusing on healthy behaviors that produce positive change. This program emphasis contributes to family empowerment.

Families are recruited through referrals from HSC staff, including HSC specialty clinics and collaborating programs, partner agencies that include private hospitals, Head Start and Early Head Start, and through recruitment presentations made at Career Works/Welfare to Work orientation classes.

Once families have been identified as meeting the SELECTT criteria, they are assigned randomly to a treatment group or a control group. Both groups receive case management services, although those in the control group receive a minimum of 4 hours of case management per year (including two home visits), and a structured assessment and service protocol. It is important to note that SELECTT pays for a case manager to provide limited case management services to all its control clients. This case manager is co-located in the SELECTT office, attends SELECTT staff meetings (but not the Family Services Delivery Plan meetings), and has access to developmental staff as resources for consultation. Although it may appear that the same guidelines for service are followed for both intervention and control groups, the intervention group benefits from a more intensive set of program components: case management, interdisciplinary team involvement, and more direct services.

The Collaboration
The SELECTT program was originally implemented as an expansion of the HSC's Los Pasos Program, which provides case management and integrated service teams for children and families affected by prenatal substance use. SELECTT is distinguished from other collaborative efforts in Albuquerque by its expanded enrollment criteria (see "Families Served," above) and its strong home-based case management approach, coupled with the location of integrated service providers in a single clinic setting, the Family Practice Clinic at the Family and Community Medicine Department. There, the entire family can receive medical services during one clinical visit.

As a result of its programmatic efforts toward service integration, SELECTT successfully merged with three other programs at the HSC in order to provide a continuum of services for high-risk children and their families. In addition to SELECTT, the new program merger, FOCUS (Family Options: Caring, Understanding, Solutions), now includes Los Pasos; GRO (Grandparents and Relatives Outreach), a project for kinship caregivers; and the Milagro Program, a perinatal substance abuse program for women and children. This new collaboration will enhance services across the four programs by offering a wider spectrum of services, cross- training, streamlined documentation, and eventually, a pooling of financial resources.

SELECTT's Steering Committee meets monthly with its HSC and community collaborators to discuss program policy, service issues, and other issues to ensure that services are provided to the families. The principle investigator and program manager are heavily involved in a variety of ad hoc and formal groups at the local and State level, whose goals are to further systems and services integration in specific service areas, such as domestic violence, child witness to violence, early intervention, health care/Medicaid issues, home visiting, and mental health/substance abuse.

Engaging in Relationships With Families Through Child- and Family-Centered Services
SELECTT provides services for its children and families in three locations: at home, in an integrated HSC clinic held one day per week at Family Practice, or in the SELECTT offices. The intensive case management team is a strengths-based, solution-focused approach to engaging and working with families. All service assessment and provision is predicated on the belief that families will become more productive if they focus on healthy behaviors that produce positive change. The solution-focused approach utilized by the highly supportive and flexible case management staff as well as the integrated service providers is believed to produce higher levels of engagement and, subsequently, stronger families. The impact of this approach is being evaluated by the local evaluation team.

Several specialized features of the SELECTT program's intervention group characterize its services. (1) Families receive intensive case management utilizing a solution-focused approach. This approach emphasizes a working partnership with families in making good choices for their children. (2) Most services are located in a single clinic to ensure maximum convenience for the families. Services can also be provided at home if necessary, or in any location preferred by the families. (3) All families benefit from an interdisciplinary team and case review, during which service providers discuss family goals, identify specific program outcomes, and review family progress in attaining these goals and outcomes. (4) Legal services, provided by the University's Law School Clinic, primary health, and behavioral health services are critical program components. (5) Engaging the family is a key priority of program staff and is considered to be the most important element of the program. As can be seen, the program is collaborative by its very nature.

Child-Centered Services. SELECTT provides children with primary health care services, ongoing developmental monitoring, developmental assessments, and referrals. The children's development is also monitored during home visits or while their families are attending parenting support groups. Part of the developmental evaluation includes a videotaping session of the child-caregiver interaction, which is utilized as the core team develops goals with the family. Psychological services for children are obtained through a variety of referral possibilities: through the family's mental health provider; through SELECTT's collaborator, Programs for Children and Adolescents; or obtained through a collaborative approval arrangement with Head Start psychologists or the public school, such as the Child Find program.

Family-Centered Services. The interdisciplinary team approach is pivotal to service implementation for families. The core SELECTT intervention group is composed of three clinically trained case managers, three caseworkers, and two developmental specialists. Each case manager is paired with a caseworker to provide intensive home- and office-based case management. The case manager assists the family in identifying family goals, which are presented to the interdisciplinary team at the family service delivery plan (FSDP) meeting. In addition to the family's goals, the entire team participates in the assessment of the family using a risk assessment instrument developed specifically for this project. This assessment leads to the identification of specific programmatic "outcomes" in the FSDP.

The Milagro Program, the HSC treatment program for substance use, using perinatal mothers, provides substance use counseling to SELECTT women. Recently, SELECTT began offering mental health counseling at the SELECTT offices through the services of a counseling intern, who is supervised by a consultant psychologist at the SELECTT site. This program enhancement has resulted in an increased response rate for behavioral health needs. In addition, all staff are trained in solution-focused techniques, an approach that complements mental health treatment services when access to these services is limited or when they are refused by the families.

In SELECTT, families also have access to parenting group sessions, ongoing parent education, anticipatory guidance, and a Family Solutions Committee, as well as legal services and assistance with referrals to appropriate outside agencies. Caseworkers are in frequent contact with the family by offering parenting education, support, and assistance between home visits. Developmental specialists are used to help assess and monitor developmental progress and conduct parenting groups. The developmental specialists also conduct a formal parent education and support group, offered twice a month in the SELECTT offices.

The classes have not been consistently well attended because most caregivers work and cannot attend the classes, which are held on Mondays from 11:00 a.m. to 1:00 p.m. (lunch is provided). Classes are not offered in the evening because many of the families live in outlying areas and Albuquerque has virtually no public transportation in the evenings. Consequently, most parenting guidance occurs during home visits by the core SELECTT team.

The Challenges
Many challenges face the SELECTT program, particularly in light of changes in the welfare program, which mandates that head of household family members must either be employed or attending classes. That very requirement hinders families from engaging in the program, such as attending parenting groups, legal assistance appointments, substance use, mental health treatment, or counseling.

Transportation is an overwhelming barrier in Albuquerque. In fact, families on the Families Solutions Committee have identified this as one of the primary barriers to services.

Another barrier is the need for more comprehensive psychological services for children and their siblings in the community. The social-emotional needs of the children are not being adequately addressed in this area. SELECTT is attempting to meet this need in the face of managed care issues, insufficient numbers of psychologists who treat young children, and the lack of understanding at the public school, daycare, and preschool settings about the social-emotional needs of the children. However, through active participation on committees and through its success in mobilizing the Albuquerque and New Mexico community at its "Community Forum," held in Albuquerque in October 2000, there is a high expectation that these barriers will be addressed and, hopefully, overcome.

Casey Family Partners: Spokane —Washington

    Program Population:

• Families Referred from Child Protective Services
• 0 - 3 Years
• Urban

    Program Services Include:

• Developmental Services
• Physical Health Services
• Mental Health Services
• Chemical Dependency Services
• Basic Family Needs
• Parent Education and Support

    The Setting
Casey Family Partners: Spokane (CFPS) provides assessment and treatment to children and families who have been referred to Child Protective Services (CPS) for child abuse or neglect. CFPS has one location in Spokane. Child Protective Services or CPS-funded nurses and social workers refer families to Casey Family Partners at early intervention programs when they suspect child neglect.

The Families Served
CFPS is the referral choice for the highest risk cases because of the multidisciplinary approach and the focused effort to meet any relevant service need for all affected family members. Although CFPS serves families affected by both abuse and neglect, only neglect cases are eligible to participate in the SESS study. SESS families must include children from birth to 30 months. The goal of CFPS is to restore children and their families to a healthy, productive life. As in other SESS programs, research and evaluation of the program is part of the project.

    The Collaboration
CFPS develops and implements an effective interdisciplinary, integrated service strategy, which is shared and replicated by other community service systems. CFPS provides primarily in-office medical assessments and intensive team facilitation, relying on collaborative partners for treatment services. Collaboration teams help integrate services. Multiple policy and service groups meet regularly to manage the SESS program. As a result, many providers have developed strong ties to their community and to each other, which strengthens their commitment to SESS.

In several instances, collaborative agency staff are located at the Casey Family Partners site. Following are the major collaborative public and private partners working with the SESS project.

Division of Children and Family Services, Child Protective Services. This collaboration is critical because CFPS depends on CPS for referrals into SESS. CPS social workers share case coordination responsibilities with SESS case managers. Two CPS social workers are located at CFPS to consult on family plans and ensure that families receive court-ordered services.

Spokane Regional Health District (public health agency). CFPS has its own medical staff whose members provide comprehensive medical evaluations of child sexual and physical abuse and neglect, then coordinate their findings with the child's primary care provider. If the child is not enrolled in a medical care plan, Casey staff members help to enroll them. A public health nurse experienced in early intervention with families referred for abuse and neglect is co-located at Casey.

Deaconess Chemical Dependency Treatment Services. The chemical dependency treatment program operated by Deaconess Medical Center moved its entire outpatient women's treatment program into the CFPS offices shortly after SESS was funded. All of Deaconess's female clients receiving chemical dependency treatment come to the CFPS office, whether or not they are CFPS clients.

Spokane Mental Health (private agency). Because so many SESS clients need mental health services, four mental health therapists from Spokane Mental Health work at the CFPS offices. These therapists work closely with staff from Deaconess Chemical Dependency and are highly involved in SESS policy and staff meetings.

WorkFirst (welfare to work program). Because about 80 percent of CFPS families are welfare recipients, a WorkFirst representative attends collaborative meetings at the organizational level, and may be a part of Family Team meetings if the family wants them to be present.

Engaging in Relationships Through Child- and Family-Centered Services
The family's goals are reviewed at the Family Team meeting, progress or problems are noted and discussed, and decisions are made about what should be accomplished by the next meeting. The focus of this meeting is family participation in decisionmaking and integration into one family service plan, the goals of the child welfare, mental health, and chemical dependency interventions. The case management provided to SESS families builds on their strengths and the program focuses on the service needs of both the children and the parent.

The SESS program offers the following services:

Developmental Services. A nurse practitioner, who serves as the developmental specialist, monitors a child's developmental status every few months, and makes referrals for further assessment or services such as speech therapy or attachment disorders. Problems that are beginning to manifest in the child due to neglect are assessed and treated as early as possible by CFPS.

Physical Health Services. Medical staff (pediatrician, RN, pediatric nurse practitioner, medical director, for a combined total of 48 hours per week) provide physical exams and referrals for immunizations for youth, assess failure to thrive, treat some infections and asthma, and make referrals for dental care and other service needs. A co-located public health nurse provides home visiting, developmental evaluations, and parenting skill development. Adult physical health needs are not systematically assessed, but referrals are made as needed.

Mental Health Services. Two full-time equivalent mental health therapists are available for assessment, child play therapy, and adult cognitive/ behavioral therapy. Referrals are made to Spokane Mental Health for serious behavior or attachment problems. Between 50 and 75 percent of the SESS families require mental health services (along with chemical dependency services).

Chemical Dependency Services. Case managers estimate that more than half of the families at CFPS need chemical dependency services. Chemical dependency is often at the core of the problem for which the family was referred to CPS, and usually the parent has been in treatment before. Prevention services consist primarily of a relapse prevention support group held at the CFPS offices.

Parent Education and Support. A parent-child interaction lab is held weekly. Case managers and developmental specialists view the parent-child interaction video and discuss attachment and parenting issues. CFPS offers a weekly fathers support group that focuses on responsible parenting. Much of the parenting information is shared informally by the family team coordinator during home visits or during meetings while the family is waiting to receive services in the CFPS office.

Foundation (Basic) Services. CFPS will do anything it can to meet basic needs of families. A food bank and WIC programs are located in the CFPS office and are available to SESS families. SESS staff will intervene with utility companies, landlords, and other agencies to ensure that families have their basic needs met. In addition, CFPS has established a fast-track referral agreement for its clients with Northwest Justice Project for needed civil legal services.

The Challenges
Some Child Protective Services social workers have expressed concerns about participating in the SESS research: (1) It is difficult to accept random assignment, half of the families they refer are accepted into Casey services, half continue to receive CPS-services-as-usual. This is disappointing to the social workers who referred for the team approach; (2) The idea of being "compared" in this way has made some CPS social workers feel they are cast at a disadvantage; (3) If the research shows the team approach has better outcomes, would that undercut job security for CPS social workers? The principal investigator for CFPS responded to the concerns in the Human Subjects Review Board approval, but the questions themselves had a chilling effect on referrals from some CPS social workers.

Another challenge was accessibility and availability of mental health services as the county system for contracting with providers underwent changes in definitions of medical necessity. CFPS wrote a State juvenile justice grant to fund one full-time equivalent (FTE) mental health therapist, which was then matched by one FTE therapist. The two are co-located at CFPS.

• eliminating the stigma that impedes prevention, treatment, and rehabilitation services for individuals with substance abuse;
• developing, synthesizing, and disseminating knowledge and information to improve prevention, treatment, rehabilitation services, and improving the organization, financing, and delivery of these services;
• providing strategic funding to increase the effectiveness and availability of services;
• promoting effective prevention, treatment, and rehabilitation policies and services;
• developing and promoting quality standards for service delivery;
• developing and promoting models and strategies for training and education;
• developing and promoting useful and efficient data collection and evaluation systems; and
• promoting public and private policies to finance prevention, treatment, and rehabilitation services so that they are available and accessible.