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WINTER 2008
CONTENTS FEATURES 14
19
Silent Storm
Minnesota Thrive The Key 3 Brochure Mental Health
Inside Minnesota’s Youngest Minds
23
Peace of Mind for our Youngest Kids
Disorders of Young Children
30
34
38
The Kid’s Instruction Manual
Kicked Out
The Long & Winding Wait
Is Mental Health behind Minnesota’s Childcare Essential Tips for Raising Expulsions? a Socially & Emotionally Healthy Child
Mental Healthcare Shortages Leave Families Hanging
DEPARTMENTS 4
6
Beginnings Emotions
What Babies Wish We Knew
The Home Front
Even Infants can have Mental Health Issues
Deployments Ambush Minnesota’s Youngest Children
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44 Gray Matter
48 Keynotes
Kids’ Mental Health Coverage Not Black and White
52 Guest Editorial 10 Mom, Interrupted
46 Age of Innocence
Postpartum Depression Takes Toll on Infants, Too
Like a silent storm, early childhood mental health problems are voiceless and threatening in Minnesota.
“Our mission is to unlock the power of central Minnesota people to build and sustain healthy communities.”
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INITIATIVE FOUNDATION GOALS Pine
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Mind Your Business
More Young Children Forced to Cope with Parental Incarceration
Cass
COVER
The Initiative Foundation Newsletter
Chisago
Strengthen Economic Opportunity Preserve Key Places and Natural Resources Support Children, Youth, and Families Build Organizational Effectiveness Encourage the Spirit of Giving
A Visit With a Friend
BEGINNINGS
Emotions Dear Friends, Young children are complex.
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My husband, Neal, and I learned this lesson twenty-four years ago, when we brought home our twin boys from the hospital. We tried to prepare our two-year-old daughter, Melanie. We told her that we would always love her and she was still special. She hugged us and said she loved us, too. When we burst through the door holding a baby apiece, we expected an unforgettable family moment. We got one. Cross-armed and scowling, Melanie hinted at her disapproval by having a “potty accident” over the heat register. Little girls are so cute. It turns out that she had room in her heart for only one baby brother. She fawned over Mark and ignored the existence of Luke. She wouldn’t even look at him or talk about him for a couple of days and she defiantly clung to “Marky” as her baby. Melanie’s actions affirmed to us how much we didn’t understand about our kids’ emotional health. It’s a trend that many families are experiencing today. Minnesota healthcare professionals report a steady increase in early childhood mental health problems that are far more serious than sibling resentment. No one can pinpoint why, but there are some theories. Stressed and splintered families and greater exposure to media violence are among them. Perhaps just as damaging is the myth that infants and young children can’t suffer from mental health disorders. Or that treatment involves Freudian couches and over-medication. That’s wrong. Busting myths is one of the reasons that we decided to take on this groundbreaking issue that no one else seems to be talking about. We’ve boiled it down for parents and caregivers of young kids, but it’s an issue that impacts entire communities. Thankfully, there’s help and hope available. Meanwhile, Neal and I just learned that Mark and his wife, Melissa, will join the ranks of parenthood in June. As you might expect, Melanie is thrilled once again. Enjoy the magazine,
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Kathy Gaalswyk, President Initiative Foundation P.S. Special thanks to the Medica Foundation, Otto Bremer Foundation, and the Minnesota Initiative Foundations for their financial and editorial support of IQ. Learn more about Minnesota Thrive Initiative for early childhood mental health on page 19.
> VOLUME 6, WINTER 2008 INITIATIVE FOUNDATION Executive Editor & Director of Communications / MATT KILIAN Grants & Communications Specialist / ANITA HOLLENHORST PUBLISHERS Evergreen Press / CHIP & JEAN BORKENHAGEN EDITORIAL Editorial Director / JODI SCHWEN Managing Editor / TENLEE LUND Staff Writer / DAWN ZIMMERMAN Staff Writer / SARAH COLBURN ART Art Director / ANDREA BAUMANN Senior Graphic Designer / BOB WALLENIUS Graphic Designer / BRAD RAYMOND Production Manager / BRYAN PETERSEN Lead Photographer / JOHN LINN ADVERTISING / SUBSCRIPTIONS Business & Advertising Director / BRIAN LEHMAN Advertiser Services / MARY SAVAGE Subscriber Services / ANITA HOLLENHORST
IQ EDITORIAL BOARD Initiative Foundation President / KATHY GAALSWYK MN Dept. of Human Services / ANTONIA APOLINARIO-WILCOXON Northwest Minnesota Foundation / LIN BACKSTROM Northland Foundation / ZANE BAIL St. Cloud Parent / TODD BLUM Southwest Initiative Foundation / SARA CARLSON Sauk Rapids-Rice School District / JANE ELLISON University of Minnesota / MICHELE FALLON MN Fathers & Families Network / MELISSA FROEHLE St. Cloud Area Child Link / CAROL GIBSON-MILLER Northland Foundation / LYNN HAGLIN West Central Initiative / NANCY JOST Initiative Foundation / LINDA KAUFMANN MN Assoc. for Children’s Mental Health / CANDACE KRAGTHORPE Southern Minnesota Initiative Foundation / ANNI O’NEILL St. Cloud State University / DR. GLEN PALM Initiative Foundation / JANA SHOGREN MN Department of Human Services / DR. L. READ SULIK Brainerd Public Schools / GEORGE TETREAULT
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Winter 2008
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SERVICE
BY BRITTA REQUE-DRAGICEVIC
The Home Front Deployments Ambush Minnesota’s Youngest Children
I
t was a magical box. It sat on the counter out of her reach. Gracie could see it better from the opposite corner of the kitchen, where she’d stand and watch, waiting. Now there was no voice, no picture. Gracie pointed to the silver laptop. “Daddy! Daddy!” she said. Jodi tried to hide the tears as reality sank in that her two-year-old daughter now called the laptop, “Daddy.” And it all made perfect sense. Daddy had been gone to war for more than a year. The webcam— and Jodi’s persistent attempts to get her daughter to, “Wave to Daddy”—had convinced the little girl that her father and computer were one and the same. It was just one of many poignant moments Jodi and Brandon Johnson of Little Falls experienced during the twentytwo months he was deployed to Iraq. And like so many military families in Minnesota, the Johnsons discovered that even the youngest of children sense that something isn’t as it was before. According to Operation: Military Kids, more than 17,000 Minnesota children are impacted by a parental deployment. They are among more than 500,000 American children under age five who are waiting for a military parent to return home. Dr. Lynette Fraga, director of military projects for Zero to Three, works tirelessly to help families and caregivers understand how young children express deployment stress and how every caregiver can support them. Zero to Three is a national nonprofit organization that supports parents, professionals, and policymakers to improve the
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lives of infants and toddlers. “Early relationships are the foundation for mental health and very young children really do miss that relationship and the sense of security that it provides,” she said. “When the relationship is disrupted, the loss is felt. Babies and young children need to know that other people LITTLE SOLDIER: Gracie Johnson (right) is among the 17,000 will be there for them.” Minnesota children who have waited for a deployed parent Immediately after Brandon to return home. deployed, Jodi Johnson noticed that Gracie changed her sleep pattern, but not much more. It (going back to earlier stages of developwasn’t until Brandon returned that the real ment), clinginess, whining, changing impact of his absence hit home. “She didn't want to be alone with him feeding, eating, and sleeping patterns— at first and would get jealous if we would these are all ways that children express be sitting next to each other on the themselves. couch,” Jodi recalled. “The first few nights, “What we want to do is keep the she would say goodbye like he was going baby in the mind of the parent, and the to leave.” parent in the mind of the baby. It’s all Zero to Three recommends that careabout staying connected.” According to Fraga, concerned comgivers create and maintain routines—such munities can raise awareness of a military as bath time, play groups, and reading family’s needs—what life is like for time—that help foster a sense of security deployed families and their children. When and dependability. Prior to deployment, seeing young patients, medical doctors and parents can videotape the deploying parent therapists should check if families have reading or playing with the child. Keeping experienced deployment, she said. photos of the deployed caregiver within “Take one day at a time,” Brandon reach of the young child, doing artwork advises reunited families. “You have to together, talking about the deployed paradjust to a new life, to find a new ‘normal’ ent, having childcare providers create projbecause things will never be the same as ects to send to the deployed parent—all are before. All three of us have changed. Just ways to help ease stress on children. “Little children cannot express what take one day at a time.” they are feeling with words, so they act React at IQMAG.ORG out or withdraw,” Fraga said. “Regression
Winter 2008
7
EARLY LIFE
BY NANCY LEASMAN
What Babies Wish We Knew Even Infants can have Mental Health Issues
W
hen C.C. was born at the Willmar Hospital, her parents were thrilled. From prenatal vitamins to nursing, her mother tried to do everything right. Her father was able to be home for her first weeks. By the time C.C. was three weeks old, both parents could discern between her hungry cry and her uncomfortable cry. At three months old, she slept longer and cried less, knowing her needs would be met. Christopher was born, without prenatal care, to a single mother in poverty. With formula and diapers costing so much, Christopher’s mother often ignored his cries. At times, she watered down his formula or left him in dirty diapers. At three months old, he slept longer and cried less, knowing that his needs were unlikely to be met. So, which of these babies has the best prognosis for good mental health— C.C., who received constant attention, or Christopher, who was forced to fend for himself? “The child at age three who has had her needs met is more likely to be confident and properly attached to caregivers,” said Dr. Molly Minkkinen, early childhood professor at the University of MinnesotaDuluth. “The child who hasn’t had his needs met is more likely to act out and disassociate from caregivers.” Scientific research and extreme cases of abandonment have dispelled one of the most enduring myths of early childhood, that parents shouldn’t “spoil” their baby. In the late 1980s, thousands of
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PARENT TRAP: When Chelsea and Dustin Bleess respond to baby C.C.’s cries, they help her to build trust and attachment, not a spoiled temperament.
babies in poorly staffed orphanages suffered from malnutrition and emotional neglect. With little time to provide more than the most basic needs, nurses left the babies alone in iron cribs for hours at a time. These babies, many of whom were later adopted, exhibited severe developmental delays, as well as physical, neurological, and psychological problems. “Another challenge is that many people refuse to believe that infants can suffer from mental health issues, even those who are properly cared for,” said Linda Kaufmann, Initiative Foundation senior program manager for children, youth, and families. “It conjures up images of overmedicated children and babies on therapist’s couches, neither of which are accurate. This is a huge barrier, because we can’t deal with a problem if people don’t believe it exists.” Dr. Christopher Watson, director of professional development at the University of Minnesota’s Center for Early Education and Development (CEED), said the greatest threats to healthy infant development are due to family stressors, some of which have been present throughout history and are on the upswing today. “Among the risk factors are parental substance abuse, domestic violence, and
the lack of responsive parenting, which can be passed on from one generation to the next,” he said. Equally important is recognizing the positive impact of good parenting and encouraging new parents, as well as other caregivers, to understand their importance. “What infants and children require for healthy development are primary caregivers who offer them consistent, positive, and responsive care,” Watson added. But what about the parents who are doing their very best and yet have concerns about their baby’s development? For them it’s important to realize that they know their infant best. Consulting a pediatrician may be advised if they have concerns. Still, it isn’t always easy to discern between a fussy temperament and a potential mental health issue. “It’s important to look at a baby, not in isolation, but in the context of relationships,” Minkkinen said. “If a baby is unsoothable or not able to engage, you need to dig and find out why. If it’s not organic or biological, then you need to explore the environment.” For more information on infant mental health symptoms, visit www.zerotothree.org. React at IQMAG.ORG
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Winter 2008
9
DEPRESSION
BY DIANE MCCORMACK
Mom, Interrupted Postpartum Depression Takes Toll on Infants, Too
A
piano teacher of fifteen years, Sarah suddenly stopped playing. She didn’t want to hear music anymore. She wasn’t sleeping well, didn’t have any energy, and didn’t feel like eating. Worst of all, she didn’t want to hold her new baby. She couldn’t even bring herself to say the baby’s name. Her guilt was overwhelming. And that’s only half of postpartum depression (PPD), which affects up to 15 percent of new mothers during the first year after childbirth, according to the U.S. Department of Health and Human Services. The other half is experienced by the infant. “It feels like having a huge, heavy mantle placed on you, and the weight is so consuming that you can think of nothing else,” explained Sarah. “The thought of picking up an eight-pound baby and expending even a small amount of emotional energy is almost too much to bear.” According to the Minnesota Association for Children’s Mental Health, symptoms usually begin within the six months after childbirth. They include feeling sad, guilty or empty, a lack of energy, changes in sleeping or eating patterns, problems concentrating, or thoughts about suicide or hurting the baby. PPD affects a mother’s ability to parent. In healthy attachment, an infant learns to trust the primary caregiver, usually the mother. Depressed mothers lack the energy to carry out consistent feeding, diaper changing, and sleeping routines, reading to their children, playing or even cuddling with them. This impacts healthy development.
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“The longer the depression lasts, the more likely a long-term impact will be seen in the child’s ability to attach to others, self-regulate, develop relations with others, and learn,” said George Tetreault, a thirty-year-veteran psyOUT OF TUNE: About 15 percent of new mothers like Sarah chologist at the Paul experience the debilitating effects of postpartum depression, Bunyan Education which can cause infant mental health disorders. Cooperative in Brainerd. “Children are resilient to a point,” he added. “PPD that lasts a few weeks to a few her baby was held and nurtured as much months followed by ‘good parenting’ will as possible. probably result in the normal development To distinguish between PPD and more of the child. Children (exposed to procommon “baby blues,” a woman should longed PPD) are at significant risk for an seek medical attention if symptoms last attachment disorder, and the later developmore than two weeks. Therapy and medment of anti-social behavioral disorders.” ications are the most common and effective Attachment disorders may include treatments, according to Dr. Suzanne extreme behaviors on both ends of the Swanson, Minnesota coordinator for PPD social spectrum, from avoiding physical Support International. Support groups are contact and resisting affection to exaggeratalso helpful in treatment, she said. Online ing needs and seeking comfort from groups provide anonymity and accessibilistrangers, according to the Mayo Clinic. ty when symptoms make it difficult to get Fortunately, Sarah knew what was out of the house. wrong. Her two sisters had been through “The message is that PPD is common PPD before. “I knew that, little by little, it and very treatable, but left untreated, it can would go away,” Sarah recalls. “When it seriously impact the mental health of was at its worst, I’d talk myself through my young children,” said Jana Shogren, day, asking myself, ‘What do I need to do Initiative Foundation children, youth, and right now?’” families specialist. “Being a good mom She also had family support. While means doing whatever it takes to find help many people around the mother may find and support for you and your baby.” PPD hard to understand, Sarah’s husband React at IQMAG.ORG and other relatives helped to ensure that
Winter 2008
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Winter 2008
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By Dawn Zimmerman | Photography by John Linn
No news media are reporting on it. Few people are talking about it. Many refuse to believe it exists. The invisible statistic is that one out of twenty children has mental health problems serious enough to affect their development and that number appears to be growing. Behind the trend are young children suffering in silence, parents scrambling for answers, and Minnesota’s early childhood community joining forces to put the issue on the public radar screen. Here’s what you should know and why you should care.
Jana Shogren & Linda Kaufmann, Initiative Foundation
L
ike most two year-olds, Devon loved finger painting and making a mess. One day, that changed. Devon watched as his father struck his mother again and again, until she finally shrunk to the bedroom floor. After his father left the room, Devon scurried over and patted her back. “Mommy’s okay,” Tiffany Jacobsen would tell her young son before slipping into the bathroom to cry and regain her composure. In the days and weeks after each bout of violence, Devon started pulling away from his mom and feared what would happen if his father saw any “mess.” Jacobsen didn’t know if he would remember those moments, but she knew they were stripping Devon of his security. She also knew that they could have a lasting impact. Abusive experiences in Jacobsen’s own childhood continue to affect her as an adult. “It does make a difference,” she said. “I’m living proof of it.” National surveys indicate that one-third of U.S. children have at least two risk factors that may increase the chances of poor mental health, according to a 2006 Maternal and Child Health Journal report. These risk factors include race, existence of maternal mental health issues, parental education level, and living in poverty. At its core, mental health is simply a child’s ability to form relationships, regulate emotions, learn, and explore. While much attention has been given to the impact of trauma and a young child’s environment, many mental health disorders are rooted in genetics and biology. According to the U.S. Surgeon General, some children are born with chemical imbalances or inherit a biological vulnerability that causes them to be less resilient to adversity. “You can do everything right, and your child may still experience barriers to social and emotional development,” said Linda Kaufmann, senior program manager for children, youth, and families at the Initiative Foundation. “Traumatic events like a car accident or the death of a loved one can also trigger sudden changes in children.”
a DIFFERENT world
Increased research on early childhood development has refuted the common belief that infants, toddlers, and preschoolers are too young to have mental health problems. Today’s youngest children live in a more violent world than past generations, said Dr. L. Read Sulik, a St. Cloud child psychiatrist who now serves as assistant commissioner for Chemical and Mental Health Services for the Minnesota Department of Human Services. With the proliferation of mass media, young children may be immersed in a twenty-four-hour torrent of unsettling images, scary warnings, and conflicting messages that helps to form their sense of self and the world around them. “The world also runs at a much faster pace, and psychologically, I don’t think we’re keeping up,” said Sulik, who also believes that hectic schedules have caused families to spend less time nurturing children. “Over the past decade, I’ve noticed an increase in young children suffering from significant emotional problems.” Young children may be the most vulnerable. Medical research shows that the brain develops most rapidly in the first three to five years of life. 90 percent of a child’s brain is developed by age five, according to Zero to Three, a Washington D.C.based nonprofit organization focused on providing early childhood information for professionals, policymakers, and parents. Early childhood experiences determine how the brain’s neurons are connected, said Dr. Troy Hanson, board-certified family physician with Locum Tenens in Buffalo and a member of the State Advisory Council on Mental Health. “(Young children) do not have the capacity to process what they’re seeing, hearing, or experiencing, but they are definitely impacted by it,” Hanson said. “There’s a lot going on in the minds of children from zero to three years old.” C O N T I N U E D O N PA G E 1 8
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One of the most formidable challenges to raising awareness about early childhood mental health problems is the widespread belief that they don’t exist, or that they’re someone else’s problem. We asked three Minnesota doctors to give us their four most common myths. Here’s what they said . . . Infants and young children don’t remember events early in life, so they can’t be impacted by them. The truth is, young children may be the most vulnerable. When children feel pain or sense trauma, their bodies respond by releasing chemicals that can affect brain development
and can have lifelong effects, Dr. Troy Hanson said. He added that violence, trauma and a lack of security can damage existing pathways in the brain or prevent new pathways from forming. This research prompted several mental health associations and child psychiatrists to send protest letters to NBC for its airing of The Baby Borrowers, a 2008 reality show that placed infants in the care of inexperienced teenagers as a means of “birth control.” While babies cried, the cameras rolled. Professionals were outraged that infants, who were in the process of forming healthy attachments to their caregivers, were placed at risk of emotional trauma from being sepa-
rated from their parents. They argued that these stressful experiences could lead to fearfulness, attachment disorders, and even post-traumatic stress disorder later in life.
Holding infants every time they cry just spoils them. Crying is one of the few ways babies can communicate with their caregivers. When babies cry, they are signaling a need. “Kids are not capable of soothing themselves,” Dr. Hanson said. “Sitting there and letting them cry is not going to help them learn to soothe.” Caregivers should follow their instincts and respond to that cry, particularly in the first eight months. “The rule is that you can’t spoil a child under twelve months,” he added.
Medication & psychoanalysis are the only ways to treat mental health problems. Absolutely not. Young children are never shown ink blots or asked to interpret their dreams—that’s a myth for the movies. Medication is often the last resort when treating young children with mental disorders, said Dr. Read Sulik. Often, parent education and making changes to the child’s environment yield the best return. Early childhood interventions always involve the parent
and child together. When a child feels safe, secure, and comfortable in his environment, he can focus on playing, learning, and growing, said Dr. Martha Farrell Erickson.
It won’t happen to my child. We don’t have a family history of mental health issues. While biology plays a role, mental health isn’t always inherited. New medical research clearly shows that environmental factors such as a child’s relationship with her caregivers, exposure to violence and trauma, or feelings of insecurity can also lead to mental health issues. “It’s much more prevalent than it used to be,” Hanson added, “and it can happen to anybody.”
Sources: Dr. L. Read Sulik, Minnesota Department of Human Services; Dr. Troy Hanson, State Advisory Council on Mental Health; Dr. Martha Farrell Erickson, University of Minnesota.
HELP needed
Social stigmas and lack of access to early childhood mental health specialists make it challenging for young children to receive the attention they need—leaving many to suffer in silence. Because early childhood mental health issues are becoming more prevalent, even Minnesota’s regional medical centers have a shortage of professionals who specialize in preventing, identifying, and treating mental health issues in the state’s youngest citizens. Sulik said that many children have had to wait six to nine months just to get an initial appointment with him or his colleagues. “When you’re talking about infants and toddlers, these months are a huge chunk of their development time,” Kaufmann added. The Minnesota Initiative Foundations’ Thrive Initiative, a statewide early childhood mental health project, is working to change that. More than 2,700 parents and professionals have attended sixty-eight Thrive-sponsored training events on a variety of topics. Goals of the Thrive Initiative include educating parents on the importance of nurturing their children and educating professionals on early identification and intervention techniques. “We definitely can prevent more of our common mental health illnesses by promoting mental wellness,” Sulik said. “We can strive to have our children achieve emotional fitness just like we want them to achieve physical fitness.”
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EMOTIONAL fitness
Children need to feel secure in their environments and have their needs met in order to properly develop and grow to their potential, said Dr. Martha Farrell Erickson, an independent mental health consultant who retired from the University of Minnesota last summer. Erickson, an expert on community-based approaches and former adviser to Al Gore, said children need to connect with their primary caregiver as much as they need food. “The foundations of healthy, positive mental health are established at a young age,” she said. According to Erickson, caregivers must help children learn to regulate their emotions and behavior, develop trust and empathy, and experience a healthy amount of autonomy to develop most effectively. Preschool years, especially, are critical to laying the foundation for emotional development and for future social and cognitive learning. A child can be born with a genetic disposition of depression or another mental health disorder, but that child’s environment can shape how he or she will respond and adapt to it. “There are a lot of things that we can do to promote health, but we can still get disease,” Erickson said. “The same is true for mental health.” Modern treatment techniques for young children struggling with mental health issues often include play therapy, parent education, and environmental changes, rather than medication.
CONSEQUENCES
Without effective early intervention, mental health issues can lead to academic failure, increased crime, poor employment opportunities, and poverty in adulthood, according to the President’s New Freedom Commission report on mental health. The report found that 75 percent of girls and 66 percent of boys in the nation’s juvenile detention system had at least one mental health disorder. “We’re neglecting it significantly and we’re going to pay the price later,” Hanson said. “If we don’t start paying attention to it, the problems we’re dealing with will still be there and magnified even more.” The U.S. Surgeon General estimates that 90 percent of children who commit suicide have a mental health disorder and recently reported the highest youth suicide in fifteen years. Early childhood provides a foundation for good mental health. Tiffany Jacobsen understands the worstcase scenarios and is working to create a brighter future for her son. Now separated from her abuser and rebuilding her life, Jacobsen helps to improve Devon’s mental health by educating herself, changing the way she responds to his behavior, and participating in play therapy. Just saying his name helps rebuild trust and shows him that he is special. “If we can improve early childhood mental health outcomes,” Hanson added, “we can improve the health of our communities in the long-term.”
React at IQMAG.ORG Initiative Quarterly • IQmag.org
What We Do
Statewide surveys by Minnesota Early Childhood Initiative communities revealed that an alarming number of Greater Minnesota children are struggling with mental health issues and a striking lack of access to professional help. These surveys, national studies and heartbreaking stories prompted the six Minnesota Initiative Foundations (MIFs) to launch the Minnesota Thrive Initiative in 2007. Early childhood is the period of rapid brain development that occurs between birth and age five, often forming a blueprint for life. Mental health is simply a child’s capacity to experience and regulate emotions, form close and secure relationships, and to play. Our goals are to shatter the mythology about early childhood mental health and build powerful community action teams that work to increase awareness, early intervention and prevention efforts among families, childcare providers, and healthcare professionals.
Northwest Minnesota Foundation The Bemidji-Blackduck-Kelliher Thrive team is filling service gaps by hiring a professional to serve families in a variety of early education settings. Another project will enable mothers with mental health needs to receive services together with young children.
Northland Foundation Duluth, Proctor and Hermantown are creating more responsive and nurturing early care and education settings that ensure children are fully supported in their social and emotional development. The reflectivepractice pilot project is underway at eight sites.
Initiative Foundation The Greater St. Cloud Area is addressing shortages in early childhood mental health services. Higher education faculty joined forces with community professionals to integrate mental health curriculum into college coursework and internships.
West Central Initiative Pope County volunteers are training mentors, who successfully faced their children's mental health concerns, to help other families navigate the system. Mentors encourage parents to pursue early interventions to avoid more significant and costly issues later.
Southern Minnesota Initiative Foundation New parents at the Albert Lea Medical Center are being introduced to infant and early childhood mental health during prenatal visits and classes. Each family receives a toolkit and is invited to attend a "Meet the Baby" event to reconnect with other parents.
Communities in Action
Our approach—one community at a time. That’s why we help to recruit and train Action Teams of local leaders who care deeply about early childhood mental health. Thrive uses a proven grassroots community organizing model to engage a wide array of people at the local level. More than 400 leaders are already involved in the statewide effort.
Southwest Initiative Foundation McLeod County volunteers are coordinating parent and caregiver training efforts. Using evidence-based curricula such as the Incredible Years, they are providing a wide variety of mental health supports and interventions for young children and caregivers.
Right now, our Action Teams are working to ensure that all families have access to the information and resources they need. They reach out to families from all cultures and income levels through community events, parent forums, and early childhood activities. Each community’s top priority is to build a knowledge base and professional network for early childhood mental health resources and services in Greater Minnesota. Winter 2008
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Sources: Dr. L. Read Sulik, Assistant Commissioner for Chemical and Mental Health Services, Minnesota Department of Human Services; Dr. Glenace Edwall, Director of the Children’s Mental Health Division at the Minnesota Department of Human Services; Dr. Troy Hanson, State Advisory Council on Mental Health.
Nicholas screams, sobs and shields his eyes and ears as if the busy environment is hurting him. Hunter displays no sense of feeling, wanders impulsively, and hurls vicious words and objects at his grandmother. Craig cries for no reason, finds little joy in life, and believes that nobody likes him. Three boys. Three stories. Three unfortunate disorders that speak volumes about the importance of early childhood mental health.
“He couldn’t be in public places. He couldn’t throw something in the garbage. He couldn’t be near where a toilet was flushed. Things most kids do, he couldn’t do.”
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my and Todd Chantry knew something wasn’t right with their two-year-old son, Nicholas. When they took him to a department store, he sunk to the floor, curled into a ball, and sobbed relentlessly. He squeezed his eyelids to dodge what seemed like damaging rays from the store’s lights. He cupped his tiny hands over his ears as if the store’s commotion was deafening. His exceptional anxiety intensified the sights, sounds, and smells that surrounded him, making pleasant trips to the grocery store, zoo, or pumpkin patch unbearable for Nicholas. “He couldn’t be in public places. He couldn’t throw something in the garbage. He couldn’t be near where a toilet was flushed,” said Amy, a mother of three from Rice. “Things most kids do, he couldn’t do.” The family consulted Dr. Read Sulik, a St. Cloud child psychiatrist who now serves as assistant commissioner for Chemical and Mental Health Services for the Minnesota Department of Human Services. Sulik diagnosed Nicholas, now age five, with an anxiety disorder and set a course for treatment. “It’s totally changed his life,” Amy said. “It’s changed our life.”
Which conditions are most common? Anxiety affects about nineteen million Americans and many disorders begin in childhood and adolescence. “It’s probably one of the most prevalent mental health disorders in early childhood, but it is probably the least understood and least clearly identified,” Sulik said. Separation anxiety and social anxiety are the most commonly diagnosed anxiety disorders. Children with anxiety not only experience fear; their brain also produces a psychological response that prevents them from calming down in a reasonable amount of time. Children like Nicholas have very sensi-
tive nervous systems that trigger anxious responses easily and in greater severity. For example, a common fear of the dark can be greatly intensified in affected children and they cannot quickly overcome it.
What are the symptoms? Nicholas and other children with anxiety disorders often demonstrate what Sulik calls the “fight or flight” response. They may become agitated, exhibit combative behavior, or withdraw socially. Some experience selective mutism, an inability to speak in certain settings. Nicholas would panic in public places. His heart would race and he would cry to a point that he couldn’t catch his breath.
How can children get better? Treatment options can range from play therapy to medication, depending on how the anxiety affects the child’s functionality and development. During weekly one-hour sessions of occupational therapy, Nicholas works on skills to help him respond better to various textures of materials and food. Through behavioral therapy, he learns how to calm his fears and become more aware of trigger points, such as tightened muscles or a stomach ache. Nicholas’ parents noted almost an immediate improvement in his behavior after they began practicing the response techniques they learned. Today, they are able to more effectively respond to their son’s anxieties by providing “quiet time” or holding him in a tightly wrapped blanket like a newborn. Nicholas also takes daily medication—treatment reserved for children that experience extreme psychological responses to anxiety. It was not an easy decision for the Chantrys, but one they believe has given Nicholas his life back.
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“People think that if there is no bruise on the outside, everything is okay on the inside. That’s just not the case.”
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ince his parents divorced nearly four years ago, Craig has not been his happy, energetic self. Despite his mother’s efforts to hug, hold, and reassure him, the six year-old remains scared and often bursts into tears. He will cry endlessly—often for what appears to be no reason. “He can be sitting and playing and then, all of a sudden, he’s crying,” his mom, Julie Henning, said. Many times, he doesn’t want to play with friends and often shares that he feels like nobody likes him or wants to be his friend. Even riding the school bus and starting kindergarten did not bring him joy. It’s more than the typical sadness children experience after their parents’ divorce. Craig, and his eight year-old sister, Megan, were diagnosed with depression, a disorder usually associated with adolescence or adulthood. Researchers and clinicians now recognize that children can experience depression at any age—even shortly after birth. “Severe depression is not very common in young children, but it can be very debilitating in the long term if it is not treated,” said Dr. Read Sulik, St. Cloud child psychiatrist and assistant commissioner for Chemical and Mental Health Services for the Minnesota Department of Human Services. Untreated depression is the primary cause of suicide among teens, according to the U.S. Surgeon General. Living in an abusive St. Cloud area home likely led Craig to develop depression as young as two years old, his mother said. “I was hoping it wasn’t going to have the impact it has,” she said. “I thought I hid it well enough so they didn’t see or hear it.”
Which conditions are most common? Depression is the most common mood disorder among young children. Depression affects about one in
thirty-three children, according to the Federal Center for Mental Health Services. Children are at higher risk if they have a family history or have experienced significant stress or trauma such as losing a parent, divorce, abuse, or suffering from a chronic illness.
What are the symptoms? Craig and other children with depression withdraw from friends, family, and activities that once brought them joy. They may also exhibit major changes in their eating and sleeping habits. Frequent sadness, irritability, tearfulness, and a loss of natural curiosity are the most common symptoms. Children may communicate their feelings in drawings, paintings, or play time. They may also have dull facial expressions and less responsive to hugs or holding. “People think that if there is no bruise on the outside, everything is okay on the inside,” Henning said. “That’s just not the case.”
How can children get better? The first step to treating childhood depression and other mood disorders is educating caregivers. Most treatments involve both child and family therapy. Professionals often combine cognitive therapy and play therapy to teach children how to cope with their feelings and change thoughts that affect their behavior. Craig responds well to a regular routine and talking through his feelings with his mother and teachers. Medication typically is a last resort. “We only use medications if nothing else works,” said Dr. Troy Hanson, boardcertified family physician and a member of the State Advisory Council on Mental Health.
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“It’s not that the caregiver is a bad parent or a bad guardian. It’s not that the child is bad. (These children) just can’t control their behavior. It’s a bad wire that needs to get connected.”
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urious about the world around him, Hunter began to crawl out of his crib at just nine months. At age two, he unlocked dead bolts, opened doors, and climbed over the chain-link fence that surrounds his St. Cloud home. He would wander the neighborhood, knock on a door, and ask the stranger for a cookie. Meanwhile, his grandmother—and primary caregiver—would scour the streets with police. Jan Larson realized her grandson was different. “He had no tears until he was a year old,” she said. “He would run into a hard surface, fall or become sick, but not shed a tear.” She searched for answers. At eighteen months, Hunter was diagnosed with Sensory Processing Disorder, a condition that results in what has been called a neurological "traffic jam.” It leads children to either be overly sensitive or almost numb, as in Hunter’s case. Now age three, Hunter has become extremely defiant. He throws tantrums for a full hour, argues with his “nana” at every turn, and has viciously hit her with a remote control. After more than a year of tedious research, Larson finally found a specialist who diagnosed Hunter with Oppositional Defiant Disorder. He will soon begin a new Catholic Charities program for children with ODD. Hunter’s grandmother believes that his lack of feeling and other behavioral issues are the direct results of his mother using methamphetamine during pregnancy.
Which conditions are most common? Sensory Processing Disorder can serve as a gateway to behavior disorders such as Oppositional Defiant Disorder (ODD) or Attention Deficit Hyperactivity Disorder (ADHD). ADHD has received much of the attention in the past twenty years, but ODD is becoming increasingly prevalent in young children, affecting 2 to 16 percent of school-agers. That’s com-
pared to ADHD that affects about 3 to 5 percent of children under five years old and 5 to 7 percent of school-agers.
What are the symptoms? Impulsivity, hyperactivity and the inability to pay attention are the most common symptoms of children with ADHD. Children with ODD display an ongoing pattern of uncooperative, defiant, hostile and irritable behavior. They may excessively argue, disobey or talk back to their caregivers for an extended period of time. Other symptoms include repeated tantrums, spiteful, or revenge-seeking behavior, and saying mean and hateful things when upset.
How can children get better? Children with moderate symptoms may respond to parent and child education. Play therapy, reward charts, dietary, and schedule changes may also be beneficial. While child psychiatrists often resist prescribing medications for young children, it is more commonly used to help affected children regulate their emotions and behavior. Sensory Processing Disorder sufferers like Hunter have even fewer options due to a lack of evidence to guide treatment. Some of the best known occupational therapies include brushing the children’s limbs with a soft brush. For Hunter, play therapy takes him to indoor jungle gyms and involves activities that encourage lifting, pushing, and pulling to help his body become more aware of its surroundings. “It’s not that the caregiver is a bad parent or a bad guardian. It’s not that the child is bad,” Larson said. “(These children) just can’t control their behavior. It’s a bad wire that needs to get connected.” React at IQMAG.ORG
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t three months, she is a flurry of flailing arms and kicking feet, cooing as she smiles. She is creating relationships. At thirteen months, he tastes his toys, dumps over clothes baskets, and pulls himself up on chairs. He is exploring his world. At three years, she screeches in the middle of the night. “It’s okay, honey,” comes a soft voice from across the hall. She is learning to self-soothe. These are among the first milestones of social and emotional health. They mark the ideal path of human life, the foundation of everything we are and everything we hope our children will become. If you have ever wished your son or daughter came with an instruction manual, rejoice.
You’ve come to the right place.
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JOHN LINN
have good caregivers, the brain learns to form trusting relationships and is free to explore. If a child’s life is filled with stress, tension, or abuse, the brain becomes wired for those negative situations. Children can usually move past negative experiences, but parent and caregiver support are crucial. Rather than brushing off their fears, parents should help their children work through them, Rose said. “It’s more comfortable for us to DR. TERRIE ROSE: “(Children) need to be nurtured through life’s events, believe children traumas, and stresses.” don’t remember,” she “ his is not about extraordinary—it’s about added. “They do remember and they need ordinary,” said Dr. Terrie Rose, president to be nurtured through life’s events, traumas of Baby’s Space, a Minneapolis-based and stresses.” organization that provides early education and However, a child’s behavior is often services to families in poverty. “We have good more directly related to his or her genetic evidence to show that social and emotional predisposition. For example, some children development sets the stage for life.” are hypersensitive to loud, busy environEmotionally and socially healthy children ments or new social situations. Some have will learn how to get their needs met. They’ll certain biological arousals and sensations learn how to rely on others and create relationthat they can’t control, which may require ships. They’ll learn how to regulate their emohelp from a mental health professional. “It impacts their ability to engage in relations and soothe themselves while exploring tionships and regulate emotions,” Rose said. the world around them, knowing that there’s an The good news is that parents and careadult to fall back on. These simple lessons begin in the first givers can help steer children back onto the days of life. According to Rose, early childroad of social and emotional well-being. Young hood research suggests that infants are brains are malleable and healthy interactions affected by stress and trauma in the same can reshape neurological connections. way as adults, crumbling common misconAccording to Marlys Johnson, a mental ceptions that young children are insulated health consultant for Minnesota Head Start, by a lack of awareness. children should be encouraged to express In infants, stress and trauma can manifest themselves and their wide range of emotions. as fussiness and inconsolable crying. Toddlers “We want our children to be happy,” often respond to stress through meltdowns, Johnson said. “When they’re not happy or kicking, screaming, and biting. when they’re angry or sad, it’s disturbing to us While genetics set the stage for biological and we try to shut that down.” brain development, it is experience and Instead, it’s important for kids to hear that nuance that teach the young brain how to their feelings are normal and that adults will function and learn. If a child is fortunate to keep them safe when they need to express
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those feelings. Instead of demanding that a child go to his room until the tantrum is over, Johnson said it’s better to explain that you understand that he is tired or frustrated. “When they’re whining, angry or sad, if the only message they hear is that they can’t be around us, that’s not helpful to them,” Johnson added. “We learn from them as we help them begin to calm down.” Adults can help children identify their feelings and explain how to handle anger and frustration, perhaps by taking a few deep breaths or counting out loud. Textured toys, firm hugs, or safe relaxation places can also help a child calm down. It can be difficult for parents and childcare providers to determine whether a child’s outbursts are normal, related to a stressful experience, or indicative of a serious social or emotional development issue. To help pinpoint possible challenges, the Minnesota Department of Human Services’ (DHS) Children’s Mental Health Division is promoting the national “Ages and Stages Questionnaire: Social/Emotional.” The questionnaire asks about age-specific milestones and helps to determine whether a child’s behaviors are normal. Through a pilot program that encourages doctors to administer the questionnaire during well-child checks, the department hopes it will eventually be adopted as a routine procedure. “We want to train mental health specialists and primary-care providers to look at the child early and not dismiss a mother’s concern,” said Antonia Apolinario-Wilcoxon, consultant and project coordinator for Minnesota DHS. Jana Shogren, children, youth, and families specialist at the Initiative Foundation, advises all parents and caregivers to pursue low-cost services from Early Childhood Family Education (ECFE) and Head Start, which are available in every Minnesota school district. She also recommends quality, structured programs in childcare and preschool. “Ideally, parents are a child’s first and best teacher, but parents need support, too,” Shogren said. “That’s why many resources are available, so we can develop skills and allies for the wonderful and stressful experience of parenting young children.” React at IQMAG.ORG
Strong social and emotional health are built from a foundation of daily teaching moments. If you know a young person, you’ve probably experienced these challenging situations. What’s the best way to handle them? With patience and love, experts say . . .
THE MOMENT
THE RESPONSE
THE REASON
Your three month-old is fussy and crying. You change her, feed her, and she’s still not happy. You worry that responding to every cry will teach her to cry for everything.
You can’t spoil a baby—that’s a myth. Responding to your newborn’s cries teaches her that she can rely on you. She also learns that she is an effective communicator.
These experiences allow her to develop a strong trust in others and in herself. They teach her that the world is a good, safe place and that she can play an active role in it. Security gives her the freedom to explore.
Bedtime for your seven month-old is a nightmare for you. You lay him down and he immediately cries and fusses. People tell you to give him time to fall asleep on his own, but you feel guilty.
Set a bedtime routine that offers your child predictability. Consider a warm bath, a book, and a soft toy to cuddle. Predictability helps children feel more secure.
When you provide a special routine for your child, he learns that he is important. Allowing a child time to put himself to sleep without rocking or feeding teaches him to self-soothe.
You drop off your one-year-old at childcare. She cries and clings to you. When she becomes distracted by a toy, you consider slipping out the door without saying goodbye.
Experts agree that it’s better to say a loving and quick goodbye even though it’s likely to incite a tantrum. Once you walk out the door, the crying will likely stop within minutes.
Developing a goodbye routine paired with happy reunions teaches your child to trust that you will return. It builds a child’s confidence in you and your relationship.
Your two year-old is developing a myriad of fears—fear of bees, fear of going to the doctor, fear of the dark, fear of being in a room alone.
Acknowledge your child’s fears with respect, and make suggestions for easing the fear. “Sometimes darkness can be scary. Do you want a flashlight?” Use pretend play to reenact a situation. Practicing can help build a sense of control and self-confidence.
It’s important to help children learn to cope with their fears while preserving their dignity. As you help your child gradually become familiar with the unknown, his experience mastering the unfamiliar will give him the confidence to try new things and face new situations.
When you make dinner or do housework, your three year-old whines at your feet. He asks you to play a game or give him a treat. Saying “no” elicits more serious outbursts and puts him on the edge of a full-blown meltdown.
Tell him that you understand that his feelings stem from being tired and hungry. Explain that there are rules even when he’s having a hard time—no screaming, hitting, or throwing toys. Offer calming ideas like taking deep breaths or counting out loud. Avoid telling him to go to his room until he stops crying.
Young children are easily overwhelmed by emotions. It’s important for children to know they can safely express them without negative consequences. Helping them identify causes can often provide comfort and defuse the situation.
Sources: Center for Early Education and Development; University of Minnesota Children’s Hospital KidsHealth; Early Childhood Consultants, Michele Fallon and Marlys Johnson.
Crying Foul: Annah and Eli Frost were among those searching for new childcare in 2008.
By Sarah Colburn | Photography by Jim Altobell & John Linn
It was the phone call that every parent dreads. For the Frost family, it came on Sunday evening after a long and relaxing weekend. “Oh, it’s Eli’s daycare,” Annah said before picking up. Her husband, Jeremy, could sense that something was wrong. More than once, Annah had arrived to find her three-month-old son in inconsolable hysterics. Constant holding was the only way to calm him and the provider had seven other children to handle. “I hate to do this to you,” the woman said nervously, “but I think Eli might be happier somewhere else, somewhere with fewer kids.” Annah hung up and cried. She wondered how Eli would cope. She wondered whether she was a good parent. She wondered how long it would take to find another provider she trusted. The Frost family was in a tailspin. And in Minnesota, they’re not the only ones.
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Minnesota childcare agencies are getting more referral requests from parents whose young children have been expelled from childcare settings. It’s a trend that stresses providers, parents, and children alike. When children are bounced from childcare settings in their formative years, it can affect their healthy attachments and ability to form future relationships. Cindy Croft, director of the Center for Inclusive Childcare at Concordia University, said that she receives weekly calls from distraught parents, which have steadily increased over the past few years. Expulsions have also become a popular conversation topic among her colleagues. She said that many expulsions stem from possible mental health symptoms that are often mistaken for bad behavior or bad parenting. Children may lash out, cry constantly, throw tantrums or toys, and at worst, hit, or bite other children. With 75 percent of Minnesota families regularly using childcare, the recent uptick in expulsions may pose even bigger problems for those seeking new providers. In 2007, the Minnesota Childcare Resource & Referral Network reported a net loss of 121 programs throughout the state. With an average tenure of eleven years, childcare providers work about fifty-five hours per week for less than a living wage. Many also lack support and training in early childhood mental health, Croft said. Croft added that it’s difficult for the public to acknowledge that young children have mental health needs and that behaviors are related to their development. “These kids are so little and they’re carrying these stigmas around with them.” Another witness to the steady increase in childcare expulsions, Marit Appeldoorn, is the director of preventative intervention services for St. David’s Child Development and Family Services, a Twin Cities-based program that provides training to early childhood educators and runs therapeutic preschools for children with social and emotional needs. A doubling of expulsion-related calls led St. David’s to offer more training programs and on-site consultations for preschool providers working with special-needs children. Staff members recently referred eight struggling children for additional help, after just one visit to the Northwest YMCA preschool program in New Hope. “(If a child enters) the public school system with multiple failures, they are also more likely to fail in school,” said Appeldoorn. “It can destabilize an entire family and community.” Carol Gibson-Miller of St. Cloud Area Child Link said some expulsions are linked to a lack of communication between the parent and provider. Others come after long, emotionally-draining talks and numerous changes to the childcare environment. Gibson-Miller also believes that many providers choose to avoid
Jeremy and Eli.
uncomfortable confrontations by claiming that their home or center is full, leaving parents unaware of issues and vulnerable to future expulsions for the same reasons. “They aren’t always told why or how it happened,” she said. “It’s easy to point the finger at the providers,” added Jana Shogren, Initiative Foundation children, youth, and families specialist. “But they are overworked, underpaid, and just trying to get through their day. They need our support in identifying and working with children who have special needs.” A provider armed with early childhood development training can combat that trend, picking up on cues that a child is struggling socially and emotionally, not just acting out. State and nonprofit agencies are offering more workshops in early childhood mental health, but they are not yet mandatory. Licensed providers in Minnesota are only required to have training in Sudden Infant Death Syndrome, Shaken Baby Syndrome, CPR, first-aid and two hours of child development. Home providers must have eight hours of continuing education each year. Without advanced training, providers must rely on their own experiences to help kids. And though some providers simply won’t make changes to the environment when a child is struggling, many more go above and beyond. Mary Anderson, co-owner of Kids Incorporated in Hutchinson, represents the next generation of Minnesota’s professional childcare providers. She is responsible for more than fourteen children with special social and emotional needs, many of whom have been expelled from four or five childcare programs before finding hers. “We’re not going to remove a child at the first sign of a problem,” Anderson said. “The child doesn’t need one more challenge.” Anderson said that she can immediately spot a child’s outof-bounds behavior when they come through her door. While many parents are hesitant to explain
why they left their previous provider, she said that information is vital in order to create a new, sound relationship. Even Annah Frost admits that she withheld information during her first provider interview, afraid that she wouldn’t find another place for Eli. Eventually, she asked questions about how each provider would handle constant crying. Today, Eli’s new provider communicates regularly with Annah and Jeremy about his day and any changes to his schedule or environment that could affect his mood. Anderson documents behavior concerns and discusses them with parents to see if the behavior may be caused by any major traumas or upheavals in the child’s life. Then, she adjusts the childcare environment accordingly, sometimes shortening a story time for those who struggle to sit still or providing a quieter space for overstimulated infants. “It’s like finding a key to a lock and once you unlock it you can deal with it,” Anderson said. Mary and other Minnesota providers are also giving themselves a time-out from the childcare setting to learn new strategies and talk to each other. The practice is called “Reflective Consultation,” linking providers with peers and mental health experts to step back and think about a child’s behaviors, identify possible causes, and reflect on their personal feelings and experiences. Along with parent communication and continuing education, Reflective Consultation is being hailed as a model to substantially improve childcare at all levels. Marcia Schlattman, program manager of Childcare Resource and Referral, said her agency is hoping to provide support for professionals who don’t have many opportunities to connect with their peers. Annah Frost advises other parents to maintain an open line of communication with their childcare provider and consider a change if a child continues to have challenges. For all the stress she endured, she considers Eli’s expulsion a blessing in disguise. “We probably would have stayed, had she not asked us to leave,” she said. “Now, it’s really night and day about how I feel about Eli going to daycare.” For more information about choosing childcare, local availability, special needs programs, and provider resources, visit the Minnesota Childcare Resource & Referral Network at www.mnchildcare.org. React at IQMAG.ORG
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Six months of waiting. Six months of wondering. Six months of watching your child suffer from the inside out. Six months of guilt, stress and helplessness. Six. Months. Such is the slow-motion waiting list for an appointment with Minnesota’s thinly scattered child psychiatrists and early childhood mental health professionals.
Welcome to the race against time.
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ris Beehler remembers her exact breaking point. Her three year old son, Landon, had his head down on a restaurant table, both hands clamped over his ears, crying and screaming that the noise was too loud. “I said, ‘enough is enough.’ Something needed to be done right then.” Landon was put on a waiting list to see a child psychiatrist in St. Cloud, a list that can linger for six to nine months, according to area healthcare professionals. “They said they would call if there were any cancellations, but there weren’t,” said Kris. So the Beehlers waited, watching their two-year-old son become more and more troubled. “There’s such a high demand for child psychiatry, there just aren’t enough doctors.” GOOD CALL: When Landon Meanwhile, early childhood experts say that (right) revealed extreme anx ieties, the Beehler family Carol Gibson-Miller (left) contacted at St. Cloud Area Child Lin mental health issues can be hardest hitting during a k for help. child’s first five years of life, when the brain develops at a rapid pace and social and emotional connections are formed. “Family doctors are trying to be the first line of defense,” she added. “Many affected kids will experience challenges in school and later in “Often they are the only line of defense, since many areas don’t have any life,” said Nancy Jost, early childhood coordinator at West Central mental health professionals who will see children under the age of eight.” Initiative in Fergus Falls. “Simply put, they can’t wait for help. And right The field of infant and early childhood mental healthcare is a relanow, they have no other choice.” tively new frontier. The patients are frequently too young to talk, and the best interventions usually involve therapy and observation sessions conducted with parents or caregivers, either in the child’s home or childcare There is a documented shortage of licensed early childhood mental setting. Frequently, the time commitment is higher and the pay scale health professionals throughout Minnesota, especially in rural areas. lower than if a practitioner focused on older patients. Jessica Croatt Niemi, mental health professional with Stellher Human “We don’t have a lot of licensed therapists that work with children Services in Bemidji, has been advertising to hire a mental health profesunder the age of five,” said Carol Gibson-Miller, interagency service coorsional for two years. “They don’t even need expertise with families of dinator at St. Cloud Area Child Link, a program that connects family young children,” she said. “I’m willing to provide and pay for that trainresources for young children with special needs. “I think a lot of mental ing, yet we’ve had very little response.” health professionals don’t feel well-trained in early childhood, so they just It’s a familiar challenge for Sandy Tubbs, director of Douglas County stay away from it.” Public Health, who said that the Douglas County Hospital has continually tried to recruit a child and adolescent psychiatrist. “It’s a huge, ongoing challenge,” she said. Such shortages of trained personnel can result in long waiting According to Dr. Troy Hanson, board-certified famiily physician with lists and insufficient doctor visits. “In rural Minnesota there may be Locum Tenens in Buffalo and a member of the State Advisory Council on one child psychiatrist within a 150-mile radius,” said Sara Carlson, Mental Health, his family practice education provided no training in early program officer and early childhood specialist with the Southwest childhood mental health. In order to better serve families with young chilInitiative Foundation. “Parents drive two hours one way for a 15dren, Hanson pursued additional training on his own, enrolling in the minute office visit, and then they’re put on a waiting list for months new Infant and Early Childhood Mental Health Certificate Program before they can get in for services on a regular basis. through the University of Minnesota.
The Rural Drought
Train of Thought
CONTINUED ON PAGE 42
Mental health issues can be hardest hitting during a child’s first five years of life, when the brain develops at a rapid pace. “Simply put, they can’t wait for help.”
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CONTINUED FROM PAGE 40
“A lot of the problems that I see in the clinic or the emergency room have some component of a mental health issue within them,” Hanson said. “Parents usually go first to their primary care provider with questions about their babies,” said Antonia Apolinario-Wilcoxon, mental health program consultant with the Children’s Mental Health Division of the Minnesota Department of Human Services (MDHS). Wilcoxon coordinated the MDHS-facilitated Great Start Minnesota Project, a three-year program to introduce early childhood mental health screening into primary care practices. She said the Diagnostic Classification Zero to Three program has trained more than 1,000 mental health professionals and 300 primary care providers at 15 statewide sites. “My dream would be that we would have, at every clinic, all of the LPN and RN level staff, the nurse practitioners, and the physicians at least aware of this training,” Carlson added. “I would love to see mental health screening being done routinely for all children.”
Difficult Diagnosis Well-baby visits offer the perfect opportunity for routine screening, but screening doesn’t always lead to a definitive diagnosis or treatment plan. Landon Beehler has what his mother, Kris, describes as, “‘the fivebucket syndrome.’ You put five buckets in front of you with different diagnoses and take a little bit out of each bucket. “The psychiatrist said it’s hard to diagnose at such a young age, but it seems that Landon has a little bit of everything—obsessive-compulsive disorder, ADHD, Turrette’s, depression, Asperger’s. There’s not enough to diagnose any one thing.” Then there is the stigma of a mental health label, which many practitioners avoid applying to very young children. When testing and diagnostics don’t point in a specific direction, they may use a diagnostic code like “Pervasive Developmental Delay-Not Otherwise Specified” or “Disorder of Infancy or Childhood-Not Otherwise Specified.” Such ambiguous diagnoses may also affect a family’s ability to get further testing or treatment covered by health insurance. “There are more services available for children and families when there is something diagnosable,” said Susan Schultz, licensed psychologist at the Infant Parent Psychotherapy Practice in Edina. “I might use a generic code for a child that is never going to get a spectrum diagnosis. It just means that development is derailed in a couple of areas.” According to Dr. Hanson, it is difficult to provide a specific mental health diagnosis in young children because many problems have similar symptoms or behaviors. “To distinguish those and figure out exactly what they mean in early childhood can be very difficult.”
Collaborators Wanted Healthcare leaders agree that improving collaboration among providers would be a major step forward. Patient confidentiality presents a major barrier. With mental health issues, patient records become
Dr. Troy Hanson.
proprietary. A referring physician may never be informed of his patient’s diagnosis or treatment. However, two separate pilot programs are tackling this issue. One, instituted by PrimeWest HEALTH, utilizes a clinic care coordinator to take the referral from the primary caregiver, connect the family to the recommended mental health professionals or community organizations, follow up, and keep everyone informed. Another approach explored by St. Cloud’s CentraCare Health System involves bringing a mental health professional into the clinic, so that he or she is accessible to primary caregivers and families. “CentraCare found ways to make this work, financially and operationally, to provide something their patients needed,” ApolinarioWilcoxon said. The Beehler family had to take a different route. Their family doctor referred Kris to the Foley school district, which then referred her to Gibson-Miller at St. Cloud Area Child Link. Within a week, a speech therapist, a child psychologist, and Gibson-Miller visited the Beehler home to conduct initial assessments. Landon, who is now four, is enrolled in an early childhood preschool designed to help him adjust to a classroom environment. He is taking medication, and the family has learned coping techniques to help ease difficult situations. “Infant and early childhood mental health, from my perspective, is really about understanding the social-emotional development of very young children,” Gibson-Miller said. “Teaching strategies to support whoever is touching the lives of children ages zero-to-three will make a lifelong difference in our families and our communities.” React at IQMAG.ORG
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INSURANCE
BY TENLEE LUND
Gray Matter Kids’ Mental Health Coverage Not Black and White
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our three-month-old infant is constantly irritable and squirms uncomfortably when you try to comfort her. The doctor can find no physical malady, but you’re worried that things just don’t seem “right.” After you answer a questionnaire about your infant’s routine and responses, further mental health assessments are recommended—and that’s when you find out your health insurance won’t pay for them. Now what? Can you afford to pay out of pocket? Can you afford not to? Why aren’t these assessments covered for young children?
“This concept could reform how we pay for healthcare,” Bence said. “It’s being talked about at the national level, but Minnesota actually has legislation that is moving it forward.” At this point, traditional health insurance still isn’t designed to cover early intervention or prevention for children’s mental health, according to Rep. Larry Hosch of St. Joseph, Minnesota. As vice-chair of the Health and Human Services Finance Committee, Rep. Hosch is among state legislators working to reform mental healthcare and coverage.
medical clinics requires all PrimeWest children to be screened during well-baby visits. Questionnaires are administered and tabulated while parents and children are in the waiting room. “The doctor already has the questionnaire results and can discuss them with the parents right away,” said Jeanne Barlage, PrimeWest depression disease management/integrated shared care manager. The doctor decides if the child needs further diagnostic assessment, and under PrimeWest, it’s all covered by insurance. Douglas County, which includes
“The system is set up to pay only for the person who is experiencing the difficulty, no one else. Many times, you can’t treat young children without their caregivers being involved, but insurance doesn’t always pay for family therapy.” “Mental health coverage varies widely by insurance provider and plan,” said Sara Carlson, program officer and early childhood specialist with Southwest Initiative Foundation. “The system is set up to pay only for the person who is experiencing the difficulty, no one else. Many times, you can’t treat young children without their caregivers being involved, but insurance doesn’t always pay for family therapy.” Minnesota is in the vanguard of states addressing gaps in mental health coverage for very young children. According to Ken Bence, director of community health initiatives for Medica Health Plans, a new approach to coverage resembles, “the medical model, looking at mental health as any other illness.” That means providing insurance coverage for whatever treatments are prescribed in order to help the child get well.
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“One of the things we’ve struggled to recognize is how important early intervention is,” he said. “We can make significant impacts on children’s lives, families’ lives, and hopefully also save the state money in the long run.” “We shouldn’t have to apply special creative thinking to this,” said Candace Kragthorpe, director of the Minnesota Association for Infant and Early Childhood Mental Health. “If it were any other children’s health condition, it would be covered. It boggles my mind in this day and age that we do not have parity between children’s medical and mental health conditions.” PrimeWest HEALTH in Alexandria, Minnesota is rewriting the rules. Created by thirteen western Minnesota counties, the nonprofit health plan serves individuals and families on medical assistance. A pilot program at two Alexandria
Alexandria, formed one of Minnesota’s first children’s mental health collaboratives, which includes the school district, county social services, corrections, and mental health providers. “We have a unique partnership with PrimeWest,” said Sandy Tubbs, Douglas County director of public health. “They have been extremely proactive at taking away the payment barriers. It’s amazing what we can do when we don’t have to worry about who is paying for services.” According to Carlson, however, reform efforts are not about sticking the insurance companies with the bill. “We believe it’s about helping our youngest kids who can’t speak for themselves and saving money over the long-term by avoiding more expensive and less effective interventions later in life.” React at IQMAG.ORG
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SEPARATIONS
BY MARY BELISLE
Age of Innocence? More Young Children Forced to Cope With Parental Incarceration oddler Luke watched as his father was handcuffed and taken away, arrested for felony kidnapping. Luke suffers from rage and recurring nightmares. “Daddy” faded into the periphery of Luke’s life—a regret, a potential threat—who never forgot his son’s birthday. “For many prison and jail sentences, another sentence is passed along to young children,” said Linda Kaufmann, senior program manager for children, youth, and families. “Many kids suffer from emotional issues that they can’t handle. As a society, we have to support these children and not punish them for their parents’ choices.” More than fifteen thousand Minnesota children currently have an incarcerated parent, according to Parenting with Purpose, a Brooklyn Parkbased nonprofit organization. Nationally, about 25 percent of all children of incarcerated parents are age four or younger. Since 1987, Minnesota’s prison population has swelled by more than 350 percent, with the State Department of Corrections expecting to add another 2,697 inmates in ten years. “This is a growing problem for the children left behind,” Kaufmann added. The Arizona Children of Incarcerated Parents program reports that children often suffer from trauma, abuse, neglect, poverty, and the stigma that comes with having a parent in prison. Other mental health symptoms include aggression, withdrawal, excessive crying, feelings of guilt, and nightmares. In central Minnesota, the Foster Grandparent Program of Catholic
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Charities is finding itself among the organizations on the front lines. “Mentoring is an ideal intervention for children of inmates,” said Jackie Johnson, program director. The nonprofit program received a federal grant for specialized training, which has helped its volunteers reach out to local children. “I don’t have a dad—he’s in jail,” said four-year-old Tony to his foster grandmother. The boy wouldn’t obey, was often angry, and hit other children. “No, don’t touch me!” he’d yell. “I only love my mother!” “Gramma” combined her training with positive reinforcements. Eventually Tony was hugging Gramma and telling her he loved her, too. “Incarceration affects the entire family structure, encouraging the children to become like their parents,” said Joe Gibbons, executive director of the Central Minnesota Re-Entry Project for prison inmates. Intervening during a child’s formative years can break the cycle of generational crime and imprisonment, he added. Many Minnesota prisons and county jails are offering help to those who want it. Minnesota Correctional Facility-St. Cloud encourages families to visit and write to offenders. MCF-Shakopee allows overnight visitation privileges to qualified mothers residing in a parenting unit equipped with trundle beds, toys, and kidfriendly amenities. MCF-Stillwater offers four visitation days per week, staggering hours to make it easier for families. “We get great feedback from instruc-
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tors and graduates,” said Stillwater warden, John King. “It’s difficult to do much more, given my custody level and the funding challenges we face.” Through its Children, Youth and Families Initiative, the Initiative Foundation is laying the groundwork to help community coalitions provide parenting education and support to children of incarcerated parents. Its Inside-Out Connections Project is receiving support from Volunteers in Service to America (VISTA). “Maintaining contact with an incarcerated parent improves a child’s social and emotional well-being,” Kaufmann said.
A CHILD’S BILL OF RIGHTS I have the right . . . • to be kept safe and informed at the time of my parent’s arrest. • to be heard when decisions are made about me. • to be considered when decisions are made about my parent. • to be well cared for in my parent’s absence. • to speak with, see, and touch my parent. • to support, as I struggle with my parent’s incarceration. • not to be judged, blamed, or labeled because of my parent’s incarceration. • to a lifelong relationship with my parent. Source: San Francisco Children of Incarcerated Parents
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Winter 2008
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> KEY STORY
CLOSE CALL Brainerd Realtor Joins Board of Trustees Tabbing strong leadership efforts in the fight against poverty, the Initiative Foundation recently welcomed Chris Close, co-owner of Close-Converse Commercial & Preferred Properties of Brainerd, to its board of trustees. “Chris’s passion for helping disadvantaged people, combined with his business and economic development expertise, makes him an excellent addition to our board,” said Kathy Gaalswyk, Initiative Foundation president. According to Close, joining the Initiative Foundation will allow him to build on his impressive résumé of commu-
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nity service, which already includes mission trips to Botswana and Malaysia, as well as a board appointment with Bridges of Hope in Brainerd. “I have always had a strong desire to participate in such a high-caliber, influential organization like the Initiative Foundation, and I am excited to be a part of their mission,” Close said. “I also hope to be instrumental in discovering out-of-the-box approaches to successfully improving the recurrence of generational poverty.” Close joined his father, Kevin, at CloseConverse in 2002, where he now specializes
in commercial and investment real estate and leasing. In 2007, Realtor Magazine named him among the top thirty realtors under age thirty in the nation. Close holds bachelor’s degrees in finance, entrepreneurial management, and marketing from the University of Minnesota’s Carlson School of Management. He lives in Baxter with his wife, Amber, and two children, Joshua and Annie.
> KEY STORY Kathy Gaalswyk, Initiative Foundation President
TAKING INITIATIVE Foundation’s 2009 Priority: Create Economic Opportunity As central Minnesota families and businesses look to regain an economic foothold in 2009, the Initiative Foundation is shifting its priorities to support them. Though the tumbling stock market has had an impact on all U.S. foundations, the Initiative Foundation plans to maintain its grants and business investments to support economic recovery. Instead of knee-jerk reactions to recent events, the foundation uses a three-year rolling endowment average to determine its annual budgets. “It’s a long-term, steady approach,” said Kathy Gaalswyk, Initiative Foundation presi-
dent. “We’ve had many great investment years to counterbalance the challenging ones.” In 2009, the foundation plans to award $1 million in nonprofit grants and $2.5 million in business loans, investing in local ownership and living-wage jobs with benefits. Ten percent of its grant funds will be tabbed to enhance workforce skills and to build the capacity of nonprofit organizations that serve families in economic distress. “Now is the time for optimism and leadership,” said Kathy Gaalswyk, foundation president. “In the 1980s, the Minnesota Initiative Foundations were created as a coun-
terpunch to economic hardship. Twenty-three years later, we don’t plan to watch and hope from the sidelines.” Gaalswyk added that all philanthropic organizations will need financial and volunteer support to sustain their safety-net operations in 2009. “Our communities and families need help more than ever, and many nonprofits are operating at maximum capacity,” she said. “Every dollar or hour of service is a symbol of hope for our region.” React at IQMAG.ORG
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GUEST EDITORIAL
BY DR. L. READ SULIK, MD
Mind Your Business A Crash Course in Early Childhood Mental Health f we don’t know where we’re going, then we’re never going to get there. As a child psychiatrist and pediatrician, I realize that if I can’t clearly define what mental health is, then I can’t help children get better. Whenever I give a presentation, I begin by asking audiences to give me their own definition of children’s mental health. Here are three common responses—1) being able to engage and relate to others, 2) being able to soothe oneself when stressed or upset, and 3) being able to explore and learn from the world around them. These three phrases sum it up. Every child deserves help if he or she is unable to explore and learn, relate to others, regulate their emotions, or self-soothe. Early childhood mental health is as simple as that. In spite of the widespread belief that young children cannot suffer from mental health problems, I have noticed an increase in young children suffering significant emotional problems over the past decade. The pace of our lives is faster than ever before. The amount of stress and pressures on families is also greater. Minnesota has a drought of healthcare and mental health professionals who are trained to treat young children. During the past several years, many families had to wait from six to nine months to get an initial appointment with me or one of my partners. Many children struggle with attachment—the relationship between a caregiver and a child. The caregiver of a well-attached child is able to successfully respond to a child’s arousal when they become overly stimulated or upset. Parents must create a warm, nurturing environment where their child can first be soothed and later develop the ability to selfsoothe. The amount and quality of affection
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shapes the development of a child’s brain during the early years. Love really does matter! However, love alone isn’t always the answer. A parent’s emotional state and a child’s biological temperament play an enormous role in how well a child can be soothed. Young children who are not easy to soothe may have “difficult” temperaments, be very sensitive to sensory stimulation, be anxious, depressed, or have other problems causing behavioral and emotional dysregulation such as ADHD (Attention Deficit Hyperactivity Disorder).
As adults, it is our responsibility to stand up for the children who cannot ask for help. A child with such behavior problems suffers in his ability to learn and receives mostly negative attention from adults. This can have a profound impact on the child’s development and sense of self. Biology isn’t always the answer, either. Children may be difficult to soothe because their parents are stressed or have their own mental health issues. Their environment may be chaotic or even violent. The inability to be soothed is often an early sign of a child who is suffering from a more serious mental health problem. All of our children need help in developing those skills that will keep them mentally healthy. They need regular amounts of sleep, healthy diets, regular physical and
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relaxation activities, and healthy, loving, supportive families and environments. I commend the leaders of the Minnesota Initiative Foundations and Minnesota Thrive for having the courage to cover an issue that few people are talking about. I hope that reading this magazine leads you to take action. As adults, it is our responsibility to stand up for the children who cannot ask for help. We need to stop denying the existence of children’s mental health problems. We need to stop condemning and stereotyping. And we need to support efforts to build awareness, affordability, and quality into early childhood mental health efforts at every level. We must do all we can to ensure that we identify those children and parents who are suffering and provide access to care as early as possible. Because sooner or later, it may be your child who needs help. React at IQMAG.ORG
Dr. L. Read Sulik is a child and adolescent psychiatrist and pediatrician. He is the newly appointed Assistant Commissioner of the Minnesota Department of Human Services, overseeing the Chemical and Mental Health Services Administration.
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