Behavioral/Mental Health Specialists in Early Education Programs:
Findings from a Survey of Child Care Directors
& Mental Health Specialists
There is growing evidence that the social-emotional development of young children is critical to
early learning and future success in school. At the same time, rising concern about challenging
behaviors and emotional disturbance exhibited by children in prekindergarten programs has
raised interest in mental health services in early education and care settings. For the purposes of
this report, the term “mental health consultation services” includes a broad array of services
provided in a variety of settings to support both behavioral and mental health needs of children
aged birth to school age.
One strategy shown to be helpful in a number of sites around the country is to have mental health
consultation available to educators and families in early care and education programs (Florida
State University, 2006). Early childhood mental health consultation typically involves a
partnership between a professional consultant with behavioral health expertise and the early
education and care program staff. Consultation services at the individual level address the
particular needs of the child and/or family. Program level consulting is focused on the overall
program or classroom and aims to help program staff develop general approaches to managing
classrooms as well as serving children with emotional and behavioral challenges (Perry, 2005;
Cohen & Kaufmann, 2000). Access to behavioral consultation has proved effective in decreasing
problem behaviors and reducing prekindergarten expulsion rates (Gilliam, 2005).
In the spring of 2007, the Department of Early Education and Care (EEC) hired Glenwood
Research to conduct a survey to learn more about the behavioral and mental health services being
provided to early education programs in Massachusetts. The purpose of the study was to learn
more about the:
• level of access to mental and behavioral health services provided in early education
• characteristics of mental and behavioral health providers;
• nature of services being provided; and
• challenges and conclusions regarding “what works.”
Surveys were distributed to (1) behavioral/mental health specialists; and (2) early childhood
program directors. Invitations to participate in the online survey were sent to programs
subscribed to the EEC Commissioner’s list-serve and to Head Start directors. Invitations were
also sent to a variety of known mental health consultants including those that had taken training
through the Massachusetts Department of Public Health, and consultants serving EEC grant
funded programs. A total of 176 behavioral/mental health specialists and 185 early education
providers completed the survey. The results of the survey, while useful, should not be
interpreted as representative of all early care and education programs or Mental Health
Consultants in Massachusetts.
Level of access to mental and behavioral health services provided in early education programs:
Specialists tend to work with multiple programs and across multiple program types.
Eighty percent of specialists are working with more than one program; 99% with center-based
programs (including Head Start and public schools); and 48% are working with family child care
The use of more than one source for mental health consultation is common among those
with access to this resource. Thirty-two percent of programs had access to one specialist while
68% have access to more than one specialist.
Programs most often receive about 10 hours of consultation a month. Seventeen percent of
programs had 0 hours per month; 39% of programs had between 1-10 hours per month; 16% of
program had between 11-20 hours per month; and 28% of programs had access to more than 20
hours per month.
Specialists work most often with preschool children and less often with infant, toddlers and
school-age children. Ninety-six percent of specialists are working with preschoolers; 53% with
toddlers; 42% with school-age children; and 34% with infants.
The surveyed programs are able to access services relatively quickly for children in crisis
needing mental health services. Services take longer for children not in crisis. Forty-one
percent of programs are able to get mental health services within one week for a child in crisis,
and 29% of children have to wait over two weeks for services. For children not in crisis, 12% of
programs are able to get mental health services within two weeks, and 53% have to wait over two
weeks for services.
Characteristics of mental and behavioral health providers:
Mental health specialists are a varied group of professionals. Twenty percent of respondents
describe themselves as a mental health or behavioral health specialist, 19% as the director of
some type of special services such as family services, early intervention, etc. and 17% as a center
director or administrator. Ten percent describe themselves as a clinical director or coordinator,
8% as a social worker, and 7% as a licensed therapist or psychologist.
Specialists are well educated and experienced. Ninety-one percent of mental health specialists
in the early education programs responding to the survey have at least a master’s degree, 8% have
a 4 year college degree, and 1% have less than a college degree. Sixty-one percent have been
working as a behavioral/mental health specialist for more than five years, and 39% have been
working as a behavioral/mental health specialist for less than five years.
Specialists responding to the survey consider themselves to have expertise in a variety of
Seventy-three percent of respondents consider themselves to have expertise in early childhood
emotional/mental health, 69% of respondents consider themselves to have expertise in
challenging behaviors and 63% of respondents consider themselves to have expertise in early
childhood education. Less than a quarter of respondents consider themselves to have expertise in
infant mental health, major mental illness, and influence of culture on caretaking practices.
Nature of services being provided:
The most common program-related activities, in order of highest to lowest frequency are:
• meeting with staff teams to discuss children or families;
• providing support to staff to support their well-being;
• engaging in direct modeling/coaching with teachers on handling issues in their
• advising teachers on classroom management strategies;
• conducting general classroom observations; and
• crisis intervention.
Activities that happen with less frequency include training for teachers on mental health topics
and advising the child care director on related program policies.
The most common child-related activities, in order of highest to lowest frequency are:
• planning for children with behavioral/mental health and disabilities;
• on-site observation of individually enrolled children;
• making referrals to community services; and
• providing direct therapeutic service to children
Activities that happen with less frequency include in-depth assessment of children, and individual
screening of children.
The most regular family-related activities are:
• meeting and talking with families about their children;
• modeling positive interactions with families that encourage them to access needed
• coordinating with other organizations;
• making referrals to community services for families; and
• case management.
Activities that happen with less frequency include providing training to families on special mental
health topics; providing direct therapeutic counseling service to families and/or together with
Challenges in providing services:
Early education programs across Massachusetts regularly serve a diverse group of children,
many of whom speak multiple languages. Ninety-three percent of programs reported that they
serve Caucasian/white children, 83% serve Hispanic/Latino children, 78% serve African-
American children, 61% serve Asian/Pacific Islander children, and 11% serve Native American
children. However, only 34% of programs strongly agreed that their specialist is able to work
effectively with non-English speaking families. Information was not collected regarding the
availability of translation services.
Culturally and linguistically competent practices need improvement. Only 16% of
specialists stated that they had expertise in the “influence of culture on caretaking practice.”
While specialists did not generally consider themselves to be experts with respect to cultural
influences on caretaking practices, 59% reported they had received information during their
training on the cultural influences on caretaking practices of infants and toddlers and 76% had
received information during their training on the cultural influences on caretaking practices of
preschoolers during the course of their studies.
Funding mechanisms are varied and often pieced together. Forty-eight percent of programs
pay directly for their mental health services. Twenty-six percent of programs do not directly fund
their mental health services, but use EEC funds to pay for their mental health services. Another
26% of programs allocate no money towards their mental health services. Programs that fund
their mental health services have more active mental health specialists, gain access to crisis and
non-crisis services faster, and receive more child, family, and program-level activities. Almost
half of the surveyed programs (43%) indicated that the mental health services they had were not
sufficient to meet the need.
Expulsion and suspension rates remain a concern. The rate of expulsion among surveyed
programs was 3.8 per 1,000 children. Respondents noted that it is difficult to refer expelled
children to appropriate services because there are not enough programs offering intensive mental
health treatment for young children. The reported rate of suspension during the last twelve
months was 5.1 children per 1,000 children in this particular sample.
The following additional barriers to working with children with mental or behavioral health needs
were identified, listed in order of highest to lowest percentage of specialists’ rating of importance:
• lack of support from parents to implement recommended practices;
• insufficient time to do work effectively;
• insufficient staff in classrooms to implement recommended practices;
• lack of funding for child care center to make recommended changes; and
• availability of mental health resources for referral.
Conclusions regarding “what works”:
Specialists are reported to be most effective in changing externalizing behavior. Specialists
and early education providers agreed on areas in which the specialist has been able to make the
• aggression towards other children;
• aggression towards adults;
• extreme temper tantrums;
• lack of positive social interactions between children;
• lack of smooth transition between activities;
• lack of pro-social behavior; and
• lack of age-appropriate emotional regulation.
A strong on-site presence of the mental health specialist enhances service. Survey findings
reflected the literature, which identifies integration of the mental health consultant into the day-
to-day functioning of a program as a best practice. In our survey, we found that programs that
dedicate funding toward their mental health services:
• have more active mental health specialists;
• gain quicker access to non-crisis mental health services; and
• reported that their consultant made more of a difference in changing problem behaviors
in the child care environment.
Programs that receive more than 10 hours of consultation per month also reported that their
specialists made more changes in problem behaviors.
While further exploration is needed to obtain a more accurate representation of behavioral/mental
health specialists and services in early education and care settings across the Commonwealth,
findings from the survey provided useful information that can guide future planning for
advancing the field of early childhood mental health consultation. In addition, an overview of
literature provided the framework to discuss the survey results in relation to best practices
identified in research.
The survey results suggest areas in need of enhancement: funding and opportunities to bill
services to insurance and other sources; professional development; cultural responsiveness; parent
involvement; referral options for children with intensive mental health needs; and emphasis on
continuing cross-agency collaboration with partners.
In addressing these areas for improvement and building upon current strengths, Massachusetts
can promote children’s social and emotional health, ultimately supporting their readiness for
school and future success.