Connecting Immigrant Communities to Infant and Early Childhood Mental Health Services

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[00:00:01.24] - Maki Park

Hello everyone. I think we're about ready to get started. Thanks so much to all of you for joining us today and especially to our speakers for being here and for being part of this conversation. My name is Maki Park. I am a senior policy analyst at the Migration Policy Institute, and this webinar is titled Connecting Immigrant Communities to Infant and Early Childhood Mental Health Services. We are holding this webinar today to mark the release of a new report on this issue available on MPI's website titled Supporting Immigrant and Refugee Families Through Infant and Early Childhood Mental Health Services. We will be taking questions for our panelists, which we'll address after each of our speakers has had a chance to give their remarks. We welcome you to use the Q&A function throughout the webinar to send in your questions and comments. You do not have to wait until the end to do that. You can also email them to [email protected] if you prefer. Um, a little intro to get us started. We are hosting this webinar at the Migration Policy Institute's National Center on Immigrant Integration Policy. At the center, we study a range of policy issues across the birth-to-career spectrum in education and training, as well as in the areas of language access and governance of integration policy.

And in addition to publishing research and reports, we also provide technical assistance to state and local leaders and other actors. And you can learn more about us and our work at our website. I'm very grateful to be joined by our fabulous speakers today, including my colleague, Lillie Hinkle, an associate policy analyst here at MPI, as well as Melissa Buchholz, state director of Healthy Steps in Colorado, and Aimee Hilado, who is an assistant professor at the University of Chicago Crown Family School of Social Work, Policy, and Practice. Our plan today is for Lillie and I to give an overview and a description of some of our key policy recommendations from the report that is being released today. Following that, we'll be hearing inspiring examples of promising approaches from the field through Aimee and then from Melissa that will really bring to life these issues and hopefully provide ideas and strategies that we all can learn and draw from. So before we launch into the brief's content, I just wanted to provide a bit of an introduction for those who may be newcomers either to the issue of infant and early childhood mental health or to the specific lens of looking at immigrant and refugee families within this context.

So according to ZERO TO THREE, infant and early childhood mental health, or IECMH, is the developing capacity of young children to form close and secure relationships to experience, manage, and express a full range of emotions, and to explore their environment and to learn, all in the context of their family, community, and culture. And increasingly in the field of early childhood, there is this growing understanding and awareness of the fact that many young children do experience mental health challenges at an early age, especially those who face poverty and other challenges to their development. And we know that promoting the socioemotional and mental health of young children has the potential to have tremendously positive impacts on their future trajectories. As the field grows, however, there is still a gap in the design and the implementation of these beneficial services that can make them less likely to reach children in immigrant and refugee families, which is what we'll be talking about today. So about 1 in 4 of all young children in the United States lives in immigrant families, 1 in 4. And the majority of these young children are US citizens. But the fact is that many of our early childhood systems and services do not account for this significant cultural and linguistic diversity in our young child population.

And this includes our mental health supports and services, which in many respects have been developed, researched, and understood from a dominant culture perspective. And we really look at this not just through the lens of understanding IECMH treatments, but beginning with mental health promotion efforts, prevention efforts, including high-quality early childhood services, which we also know that this population is less likely to access, as well as screening and assessment, another big challenge for the field with regards to cultural relevance and responsiveness. And we will be hearing more from each of our speakers about why IECMH can be particularly beneficial for immigrant families, I'm going to stop my introduction here and pass this over to my colleague, Lillie Hinkle, Associate Policy Analyst here at MPI, who will give us some of the top-line information that's covered in today's brief.

[00:04:47.17] - Lillie Hinkle

Thanks so much, Maki. It's a pleasure to be here today to talk about this issue and also expand on a few important dimensions of the brief that MPI has released today. So the issue brief really offers an overview of why infant and early childhood mental health services are important. For immigrant populations and explains the various gaps in both mainstream services and immigrant integration services. The brief highlights promising practices, some of which we'll have the opportunity to learn more about today from our expert panelists, and it proposes recommendations for stakeholders and policymakers looking to improve infant and early childhood mental health services for newcomer families that we'll touch on just a little bit at the end of the presentation. So to begin, I'd like to talk a little bit about why infant and early childhood mental health services are particularly important for immigrants. This is not to say that all immigrants experience trauma, but to acknowledge that at least some newcomers do experience various forms of trauma at different points in their migration journey. Immigrants may experience a variety of traumatic events in their home country, such as identity-based persecution, natural disaster, and other destabilizing drivers of displacement.

Once an individual makes the decision to migrate, they may be at a higher risk of acute harms like sexual and physical violence, exploitation, and environmental dangers during their migration journey, depending, of course, on which pathways are available to them. Once an individual makes the decision to migrate, they may be at a higher risk of being exposed to mental health stressors related to their integration experiences, depending on what they're coming to the United States and under what circumstances they're coming to the United States under. These are things like language barriers, social and economic hardships, and discrimination or further marginalization, things that we know to be acutely stressful. Certain immigrants must also live with a pervasive fear of legal enforcement, deportation, and family separation. A fear we know to adversely affect children. So zooming in just a little bit, I'd really like to situate what I mean when I say immigrant or humanitarian populations within the context and the scope of the current administration, the Biden administration. The Biden administration has ushered in tremendous shifts in the immigration landscape, particularly in its management of the southern border and its expansion of humanitarian protection in the United States.

Most notably, the administration has expanded temporary protected status, exercised its parole authority in its creation of processes formally for individuals from Cuba, Haiti, Nicaragua, Venezuela, and it's also undertaken emergency resettlement initiatives for populations like Afghans through Operation Allies Welcome and Ukrainians through Uniting for Ukraine. The refugee resettlement infrastructure in the wake of COVID-19 and the Trump-era destructive policies to dismantle that system are also actively in a process of being rebuilt. And this is something that the administration has really made a point to prioritize from the very beginning. But all of this is taking place as the asylum system in the United States finds itself under record strain and an increasing demand. So the current landscape is important in the context of infant and early childhood mental health because status impacts the types of information that someone receives and the benefits and services that they're eligible for, which can be a determinant factor in a family with young children's integration experience. I won't go too much into detail for the sake of brevity on all of the different nuances and, and complications with eligibility, but as you can see, There are certain populations, mostly those in the United States under humanitarian protection, who are immediately eligible for the resettlement services that are funded by the Department of Health and Human Services Office of Refugee Resettlement, or ORR, and federal means-tested benefits for low-income families.

So think about your programs like Temporary Assistance for Needy Families, Medicaid, food stamps. Some populations though are only eligible if they meet certain residency or work requirements, and some are categorically ineligible for, for anything. If you'd like to dig more into this though, I'd highly recommend checking out the, uh, report that MPI has recently put out on immigrant eligibility for a lot of these federal means-tested mainstream programs. You can scan the QR report, the QR code, and it goes straight to the report. It'll take you through each of the programs, and it's an extremely helpful guide if you really want to dig into some of the, the nuance of this. But I bring up eligibility as an important consideration because it at least in part contributes to some of the gaps we see in mainstream services. We know that health insurance plays a vital role for families that are accessing mental health services and physical healthcare services. But particularly so for low-income families for whom public health insurance programs like Medicaid or the Children's Health Insurance Program, or CHIP, may be one of the only viable options for coverage. Federal data tells us that immigrants are significantly less likely to be insured than U.S.-born citizens, ineligibility being one of several reasons for this.

Other reasons for a lack of coverage may stem from a parent's hesitance to access mainstream safety net programs like CHIP for fear of immigration consequences. Now, even though some states have expanded public health insurance to all children regardless of status using state dollars, or they've opted to reduce eligibility restrictions for immigrant children through CHIP expansion, the reality is that parents may be unaware that their child is in many cases eligible for coverage. And even for populations like refugees and asylees who receive some of the most substantial integration supports available to newcomer families in the United States through ORR-funded benefits and services, the resettlement infrastructure in its prioritization of economic self-sufficiency is not necessarily well positioned to ensure that early intervention for young children needing mental health services actually happens. That said, there are many ways that we can address these gaps and build bridges between the fields of infant and early childhood mental health and Immigration and Refugee Services. So I'll pass it back over to Maki to move through some of the recommendations from our brief.

[00:11:49.13] - Maki Park

Thanks so much, Lillie. Yeah, so we are going to move ahead now to talking about some of the key recommendations that you'll find in the brief. I'll do a pretty quick top-line overview, but our speakers will be addressing several of these in greater detail. And our first recommendation really follows in a straight line from what Lillie just shared with us about the lack of consideration for these issues and for young children within the refugee resettlement system. We really see a need to expand awareness of and promote screening for IECMH issues within the refugee resettlement sector, which currently is very focused on adults and on workforce integration. For example, the only mental health screening available for this population is the RHS-15, or Refugee Health Screener-15, which is only validated for use with folks over the age of 14. So there's no standardized process in place for screening young children and youth within this population at this critical transition point on arrival to the United States. So as a starting point, our recommendation is for the CDC and the Office of Refugee Resettlement to develop joint guidance for mental health screenings for refugee and other ORR-eligible populations to establish a standard practice for screening children and youth, given what a high-risk population this is.

Moving to the second recommendation, I did mention earlier that one of the most significant gaps in IECMH for immigrant families is just that we know that they as a group are less likely to participate in preventative early childhood services. We know that immigrant and refugees are less likely to be enrolled in formal early learning programs. However, we also know that many of these families make use of what we call family, friend, and neighbor care, or FFN care. For a large number of reasons, including the fact that this kind of care is more likely to be centered in community and have caregivers available who reflect the cultures and languages spoken by these families. Often it is the most high-quality choice for early childhood services that folks have available to them. And yet, of course, these caregivers are less likely to be supported and resourced than those working in more formal settings. In particular, Infant and Early Childhood Mental Health Consultation, which is a strategy that supports early childhood workers and caregivers with mental health services, is an important intervention that can help young children with socioemotional challenges. So expanding policy and funding parameters so that FFN providers are also able to access consultation would be one way for immigrant families to be able to benefit from this kind of support where they are.

This third recommendation I'll touch on briefly because I know Melissa will have much more to share. Uh, but pediatric healthcare providers are such an important touchpoint for families who, as I just said, are less likely to be accessing other early childhood services. Access to pediatric care is far more common, and this is an important opportunity to provide connection to IECMH services in a non-stigmatized environment. There are a lot of potential strategies to achieve this, including the provision of collaborative, multidisciplinary, and team-based care colocating resources as in the medical home model, targeted strategies that utilize bicultural and bilingual family navigators to forge those trusted connections with families, and also strategies of tracking the success rate of referrals as a key equity outcome. Not just providing a referral, but following up to make sure that that connection is achieved through a warm handoff can also go a long way in promoting connection to important services. So this is just, again, a great example of reaching families where they are. We talk next about the use of assessment tools. So in general, there's a lack of culturally relevant tools available in the many languages spoken by immigrant families.

We know, however, that instruments like the SWYC, or the Survey of Well-Being of Young Children, or the PEDS, or the Parents Evaluation of Development Status, does have licensed translations available in several languages that can be leveraged. Moving on to home visiting. Again, this is a recommendation that will be spoken to by Aimee in a moment, but we do wanna raise up home visiting as such an important two-generation and relational approach that can reach immigrant and refugee families effectively in the event that they are designed to be culturally responsive. So models that work effectively with immigrant and refugee families and/or have an explicit IECMH focus can be a great way of promoting socio-emotional health. And we would encourage states to consider the use of some of these innovative and specifically tailored models that nonetheless may not be classified as evidence-based by the Federal Home Visiting Program or MIECHV, which does not necessarily explicitly prioritize these outcomes for these populations. The next recommendation is, of course, just such an important one across the field of early childhood and beyond. But in particular within the field of IECMH, having cultural and linguistic diversity is so critical to providing high-quality care and making possible the kind of connections that enable trust and enable healing.

We heard a lot in our interviews for this brief about just the dearth of linguistic diversity and even basic translation and interpretation in the field. We also heard about the incredibly important role that folks who may not have mental health licensure or certification, but act as family navigators and liaisons to help connect families to services and really build those essential bridges, and how hard it is to get and sustain funding to hire and retain this critical part of the IECMH workforce. So as always, just finding concrete ways to value and appropriately reward language skills, cultural skills, connection to community is so essential to this work. And then the final recommendation I'll touch on is just the need for more research. A lot of the research we have available to us currently, again, is quite focused on dominant cultural norms. And we have limited empirical support for culturally specific interventions and assessments for these populations. So incentivizing and investing in research to grow this knowledge base is so important to help us understand what works and how to improve the relevance of tools and services for immigrant families. So that's a very quick crash course on the recommendations included in the brief.

Please do refer to the brief itself for more information on each of these areas. For now, I am so pleased to hand this over to Aimee Hilado, who is joining us from the University of Chicago. Aimee.

[00:18:32.24] - Aimee Hilado

Thank you. I'm a licensed clinical social worker and researcher by training. My areas of work specialize in immigration trauma and early childhood and adult mental health for arrivals here in the United States. So it's a wonderful opportunity to be on this panel and to provide an example of this work in action. Now, building off of what Lillie had shared and in the context of US immigration. Just know that the US has had a long history of being a safe harbor, having bipartisan support in humanitarian programs where there is a commitment to the US being that safe harbor for the tired and the vulnerable. But over the past decade, we have seen a change in the tone and our approach to supporting forcibly displaced immigrant and refugee populations. We have seen a change in U.S. immigration policies that have become more restrictive, and public sentiment has shifted. And the reality is that it's getting so much harder to get immigration relief in the United States. And the message is quite clear in certain states and certain communities that immigrants, refugees, newcomers are not welcomed here. And so as we think about working with forcibly displaced communities, listing out the different immigration statuses that Lillie had shared shared, know that we are engaging people and communities who leave their home country because they don't feel they have a choice if they want to live their lives with safety and dignity.

For those who choose the United States as their destination, for those who have made the United States their home for a long time, the current messaging around who is welcome and who isn't can influence mental health outcomes across the lifespan. The effects of the anti-immigrant, anti-refugee rhetoric has left a chilling effect across all communities, irrespective of immigration status, where we have communities that are directly, you know, questioning their sense of belonging, even safety. And that potentially affects some of the compounding effects of past migration trauma. And so trauma is where my work lives. It often threads the stories of people who move for survival, and it's everything on this slide. It's experienced as overwhelming. It's a threat to one's emotional, physical well-being. It leads with feelings of fear, a sense of no control, and those are experiences that can leave a person feeling helpless. Thinking about the duration, the intensity, the stage of development of when trauma is experienced, that could directly influence how you view yourself, how you view others and the world around you. And I've had the privilege of supporting refugee arrivals from 5 different global regions Irrespective of nationality, what we know with adults is that they often will share symptoms of disruptions in mood, sleep, and appetite.

They will talk about difficulty concentrating. They will talk about physical symptoms that mask mental health problems, somatic symptoms. Children and youth develop in the context of these relationships, and so they too will struggle if they don't have an adult who can model adaptive coping. And responsive caregiving and effective problem-solving. And so children and youth will struggle with the same symptoms as well as symptoms that get in the way of them forming friendships and navigating learning. So they will talk about stomachaches and headaches when they are nervous. We will observe anxious, withdrawn, even acting out behaviors. And we can even see trauma-related symptoms in our babies and toddlers in the form of babies and toddlers who are difficult to soothe, easily startled, intense attention-seeking behaviors, even regressive and aggressive behaviors that are outside the bounds of typical normative development. For the communities that I work with, intergenerational trauma is real as well. It's the trauma that's passed across generations in patterns of relationship, patterns of coping. Historical and cultural trauma is also relevant for immigrant and refugee groups. In the form of trauma inflicted on historically oppressed people because of their race, ethnicity, their religion, their immigration status.

These are identities that are experienced as a collective trauma within and across groups. And so in the 12 years that I administered this mental health program, the RefugeeOne Wellness Program, it became crystal clear the value of leveraging organizations to increase access to mental health care services It is hard to adjust to life in a new country when you are battling these experiences. We also needed to do research to keep track of our efficacy and impact efforts. As I think about displaced communities on the move, there are certain things that we know. Cumulative adverse immigration experiences can influence mental health. Unaddressed mental health needs will impact entire family systems across the lifespan. New arrivals are less likely to seek formal mental health services for the number of reasons that have been shared, but also because of the priorities of adjusting to life in a new country, learning a language, finding a job. There's a lot of misinformation about mental health care in the U.S., and sometimes there's just no information about what is available. And in the current sociopolitical climate with the rhetoric being used, there is a reluctance to engage with people and programs that are unfamiliar.

For the same fears of identification and worries about deportation. So in my work, you know, it almost felt as if when children matured into the preschool and kindergarten years, almost like clockwork, programs would connect with my program asking for consultation. Can you talk to us about who these arrivals are? We are concerned about behavioral problems. We are curious about language delays. Maybe it's ADHD. And with referrals and further assessment, oftentimes we would find it was a mental health problem a problem embedded in a constellation of needs for that young child and their family. And so we had to think as a program how to be proactive in supporting young children and their families if we wanted to interrupt the impact of intergenerational trauma and these post-resettlement realities for them. And so I thought about home visiting. I thought home visiting would be a viable pathway to be able to help newcomers adjust to life in a new country while addressing kind of the mental health needs that we're presenting, and in part because of the service delivery mechanism. Being in the home removes the barriers of having to provide or find a provider or navigate public transportation.

We get to reduce the fears of identification. We get to see the true needs of families, and it gives us a chance to figure out what additional resources this family needs. To nest a home visiting program in a known resettlement agency further allows for seamless connection to a host of other supports that could be available to the family. And so this is what we did. In 2016, I piloted this idea, implementing a home visiting program in a mental health program in a refugee resettlement agency, a very uncommon model, but one that I thought had promise. With funding from the Illinois State Board of Education and in partnership with the developers of the Baby Talk Family Engagement model, we implemented trauma-informed home visiting as a way of supporting early childhood mental health and child development, supporting caregiver mental health, providing information to support adjustment in the context of a trusting relationship that was delivered in the home. Now I want to be clear, home visiting is not therapy. It is not a clinical infant early childhood mental health service, but it can be experienced as therapeutic. Refugees time and time again had shared that sentiment with us.

It provided a pathway for talking about mental health. It provided a pathway for us identifying needs in a very safe way and getting people connected to specialized care. This refugee home visiting program has received quite a bit of interest, and so we were given an opportunity to make a video about it. And that video link is gonna be shared with you in the chat. As part of the video, you will hear findings from a randomized controlled trial that I led to really understand the potential of home visiting with refugee families. And we found significant gains for children in the area of social-emotional and language development. And we found parent gains in the areas of parent trauma symptoms and stress. And this work has been the foundation for a new study I'm leading in partnership with Chapin Hall, where we're going back into home visiting services for multilingual immigrant refugee families centering infant early childhood mental health. And so as I zoom out, complementing everything that Maki and Lillie have shared, what are the lessons we've learned? Service location matters. That we need to embed and co-locate early childhood programs and access points in the programs that immigrants and refugees are accessing regularly.

It creates an opportunity to build safe spaces to identify needs and to provide appropriate services. We have to normalize mental health terminology and create safe language to make the invisible visible. We have to be able to talk about mental health in non-stigmatizing ways. And for the program I shared, know that our resettlement agency, across the agency, we talk about mental health with all arrivals and that content is nested in home visits. So mental health is framed, communicated as essential for child development, and supporting parents is an important part of that work. We have to train clinical and non-clinical staff on mental health promotion because we cannot have any one person, one organization being responsible for mental health content dissemination. As Maki had shared, we have to have a diverse body of professionals who know how to implement universal strategies that promote mental wellness and who know how to identify when they identify mental health problems, particularly in the youngest members of our community, and then building a network of providers that can support with specialized care. Early child professionals, as mentioned, have to reflect the communities being served. At RefugeeOne, all of our home visitors are former refugees themselves, and their caseloads reflect shared language and/or culture.

They are trusted partners. They are critical cultural bridges for newcomers in a new culture, a new country, and they are the best at facilitating mental health conversations in a culturally aligned way. And then lastly, centering trauma in program development. If you know trauma is a part of the populations that you are serving, In my work, migration trauma, historical cultural trauma are all potential barriers to strong parent-child relationships and connection, and that can directly get in the way of very young children reaching their developmental agenda. And so if you know you are working with communities that have been impacted by deep-seated trauma, we have to think about ways and be prepared to provide culturally responsive, trauma-informed supports so that all families can thrive. Now, as I wrap up my points, I want to remind that immigrant refugee newcomer communities, even if they've experienced trauma, that does not dominate. Trauma and adversity narratives do not dominate their lives. There is such joy, resilience, and strength in these communities, and we don't want to lose sight of that. And so I'm so grateful for MPI for elevating this important topic And with that, I'm happy to pass the floor to my dear friend and colleague, Dr. Melissa Buchholz.

Take it away, Melissa.

[00:30:35.14] - Melissa Buchholz

Thanks, Aimee. Hi, everyone. Thank you for being here and echo Aimee's gratefulness to MPI for elevating this important topic and appreciate the invitation to present some of my work. I am a clinical psychologist by training, and what I'm going to be talking about today is the opportunity to reach refugee and immigrant families in the context of primary care settings as an opportunity to reach families in a place where many families are coming. Not all, right? There are still barriers to accessing formalized services and supports. And I think our efforts broadly across the early childhood and infant mental health system of care is to resource multiple types of providers and services so that wherever families show up, that is the right place for them to receive services. So I'm going to be talking about primary care as a place where families show up, in particular immigrant and refugee families, and how one model, the model I support here in Colorado, Healthy Steps, is an opportunity to enhance and provide infant and early childhood mental health supports in the context of primary care settings. I mentioned Healthy Steps. I just want to mention Healthy Steps is a national model.

ZERO TO THREE is the national office, serves as the national office for Healthy Steps. You can find a lot of information on healthysteps.org about the model if it's something that's of interest to you or your communities. And ZERO TO THREE provides tremendous support to practices and service providers across the country who are implementing this model. I have the privilege of supporting our primary care practices in Colorado with implementation, scaling, and sustainability of this model. And in particular, in thinking about how Healthy Steps is applicable and can be adjusted and flexible to meet the needs of the populations that are being served across the various clinics. And I'll talk about that a little bit more. So why primary care and why pediatrics? And I would say pediatrics is the word I'm using here, but I'm, I'm talking about any primary care clinic that is serving pediatric populations. So that can be pediatric primary care, it can be family medicine, anywhere where young children and their families are showing up. And the reason why this is an optimal place, one of the optimal places to serve families, particularly immigrant and refugee families, is that there is universal access.

So many families take their babies to see a pediatrician. And patients generally highly trust the pediatrician because it is a non-stigmatizing environment. I've actually often heard of it referred to as positive stigma, where families are excited to go and learn about how their baby is growing, show off what their baby is accomplishing, and really be reassured that their baby is making progress or their, their toddler is making progress in the way that they should. Additionally, the frequency of well-child visits in the first 3 years of life, and especially in the first year of life, offers us a really amazing opportunity for ongoing touchpoints with families of young children. So families often will come into their pediatrician a minimum of 12, sometimes 13 times just for regular well child care in the first 3 years of life. That doesn't even include opportunities for families to come in for ear infections or diaper rashes or things, other questions that they might have, which often bumps that frequency up quite a bit. So what is HealthySteps? Some of you may be familiar with this model, but it is an evidence-based interdisciplinary pediatric primary care program that promotes nurturing parenting and healthy development for babies and toddlers.

I always talk about HealthySteps as an opportunity to enhance the quality of early childhood and infant care to include a focus on mental health, social-emotional development, relationships. I often talk about it as the instruction book that parents never received, that when a pediatric primary care or primary care setting serving pediatric populations is able to implement this model, they are able to support families in a much more comprehensive way. They do this, and I'll talk a little bit about the core components of the model. Again, there's a lot of additional information on the Healthy Steps website, healthysteps.org. But Healthy Steps Specialists are professionals that are integrated into the pediatric team. So it is an integrated model to provide a variety of services to meet the needs of families, whatever that means for them. So That might mean there are universal services that include screening and availability of the Healthy Steps specialist, and there are more targeted specific services. And we'll talk about what each of those are and how they really support families of all walks of life and in particular our immigrant and refugee populations. The model is divided as a population health model, which is one of the reasons why it is a good fit for refugee and immigrant populations, because it's universal, meaning that all families who are patients of a primary care clinic that has implemented HealthySteps benefit from the comprehensive services that are provided with this model.

So it's a universal population health model that is risk stratified. So not all families need intensive supports. And some families need intensive supports. So Tier 1 services include screening both at the child and at the family level. So screening for child development, social-emotional development and behavior, or autism, but also screening for family needs, maternal depression, social determinants of health, psychosocial risk factors. And I just want to point out that that's really an important component of this model. To me, it feels like it is a hallmark piece of this model that it is multigenerationally focused, right? So young children and infants and toddlers show up in the context of the environments in which they exist. Aimee talked about the importance of those relationships, and we've been talking about that throughout this presentation. But those relationships are so critical. And so it is our responsibility, I would argue, in these primary care settings and across the early childhood system of care to attend to the caregivers who are supporting young children in their growth and development. And so the screenings are one way that Healthy Steps attends and supports, identifies needs that families might have, various needs, whether it's housing, food insecurity, substance use, transportation, etc., mood concerns.

And when those needs are addressed, and asked about universally, not just when there's a concern, we really have an opportunity to support families in a very holistic, comprehensive way. Some families, that is sufficient, that screening. They, you know, we screen periodically throughout those, the first several years of life, and they're doing great, right? Some families, something comes up and they need a little extra support. That could be, you know what, my toddler is biting at preschool and they're They're threatening to expel him, or I'm not really sure how to deal with my baby who's difficult to soothe, right? Or I'm really struggling with my mood. And so those are things where that kind of raises a higher level of need for that particular family. That may happen in the context of broader vulnerability, or it may happen in the context of just typical development, developmental challenges. That occur in those first 3 years of life. For families who need a little extra support, we have Tier 2 services, which are short-term support. So the most important or the key component here is child development and behavioral consults. So the Healthy Steps specialist, who again is integrated into the clinic, who has expertise in early childhood and infant development, and ideally infant mental health and early childhood mental health, is able to respond to those questions in the moment when families are already in, in the primary care space.

They're able to utilize that space, increase access to those mental health services right then and there without having to send families externally to other services that they may or may not be willing or able to access. Beyond that, some families need a lot of extra help, right? In particular, families are experiencing significant mood concerns. Caregivers are experiencing significant mood concerns. Maybe for refugee families or immigrant families who are brand new to this country, just adjusting, as Aimee was just describing, is enough to need a little extra support. And so what HealthySteps does is can offer team-based well-child visits in which the primary care provider and the HealthySteps specialist are seeing the family together at every well-child visit in the first 3 years of life. Once that family is identified as having, benefiting from those extra services. It really is a prevention and health promotion model. It is not stigmatized. We don't come in and say, it sounds like you need some extra support. I'm here to provide that. But how are you doing? How's it been being here? What new things is your baby doing? Let me offer you some guidance around what does play look like for a 6-month-old?

What— how do you introduce a bedtime routine? How do you manage picky eating, you know, for your 18-month-old, etc.? But we can, we can address those concerns, but also just be an ongoing, dependable, predictable support for families throughout those first 3 years. The 8 core components, as you could see, are divided into those 3 tiers, but really, again, are risk stratified that some families need additional support briefly, some families need support ongoing, and some families just need awareness and an identification of needs throughout their first 3 years of life. We do have some clinics who are seeing every family with that team-based well-child approach. It just depends on capacity of the Healthy Steps specialist in the clinic. But this risk stratification really leaves it open for the clinic to provide the services that families need based on their knowledge of what their population really needs. So the other piece I just want to highlight in the context of the conversation we're having today is how Healthy Steps can act as a promoter of health equity. And there are really kind of 6 key ways that I wanted to highlight today. The team-based care is really an important approach that is key and central to Healthy Steps and the way that we deliver care.

This is very different than what often is how primary care gets played out and is reinforced by our fee-for-service reimbursement system that exists in many places, most places, which really creates a fragmented care where supports are scattered throughout, ideally throughout the community, but maybe not even with the community. But having that team-based care of multiple team members with expertise, different levels of expertise can support a family with whatever that they need. Similarly, that whole family support, right? So thinking, as I mentioned, that two-generational or sometimes multi-generational approach to care versus individual care. So when a family comes into the primary care clinic, that we see the whole context of who that family is, what their experiences are, and how that is impacting that child's health, development, and wellness. Strengths-based, and I would argue also trauma-informed, is, is also an important Healthy Steps. Again, it's a very prevention health promotion model, not driven by diagnosis. So we tell our Healthy Steps practices, you don't have to have a problem to be a Tier 3 family, right, to benefit from that team-based care. You can just be benefiting from that extra support. Care coordination is an important core component of the model.

So really supporting families with What is it that you're needing? Needs identification, and then supporting really comprehensively with accessing other supports and services in the community, whether that be home visitation, mental health supports, early intervention, childcare, food resources, et cetera. And then cultural humility is really, really important for the Healthy Steps Specialist. It's a key tenet of competencies for the Healthy Steps Specialist and for the practice and general, which is really important for this population. And then in the same vein, the Healthy Steps specialists really coming at the work that they're doing from a reflective lens, that they are considering their own experiences in the context of supporting families within the primary care clinic and also building reflective capacity of the providers. So just a brief note before I wrap up about the Healthy Steps impact in Colorado. So this is a map of our, our very square state. For those of you who might be in Colorado, hello. And this is the, the shaded areas are the, the counties where there are families who are accessing Healthy Steps services. And this is just a little bit delayed. This is from last fall. So we've actually broadened our impact to the western side of our state recently, which is really exciting.

But we have 29 Healthy Steps sites currently in really diverse regions of our state. So this is the Denver area. This is our most urban region. But for those of you who are not familiar with Colorado, this sort of line, you could almost cut the third of the state down the middle, is very urban, relatively urban, and very rural on either side, on the western, western side of our state and the eastern side of our state. And we have many refugee, immigrant, asylee families throughout our state. Denver is a sanctuary city. There is, it's a, it's a really politically diverse state. And so it's been interesting to see how this has been unfolding over the last several years, as Aimee was mentioning. And so Healthy Steps is serving many families who are identified as immigrant and/or refugee. We have one clinic in particular in the Denver area that is specifically a clinic for refugee families who are brand new to our state and to the, to the country and have had, have supported that site with implementing Healthy Steps in a culturally humble, reflective way to support that particular population. And it's a moving target, right?

So the population is not uniform as, as you all know and as we've been discussing. So You know, a year and a half ago they had many Afghani families. We've had many immigrants and coming from Central and South America over the last year, year and a half as well. So very diverse within the population in general. So just, you know, reaching a broad number, we have a pretty significant refugee population. Up here in the, in the northeastern part of our state, which is interesting because they're rural but serving a large population of refugee families. So I appreciate the, just the recognition that primary care clinics, especially those who are implementing models like Healthy Steps or other focuses on early childhood more generally and focusing on high-quality Primary care that includes intentional addressing early childhood and infant mental health very intentionally is an important component with supporting the early childhood development of young children and families who are immigrant and refugee.

[00:47:33.22] - Maki Park

Thank you so much to Melissa and to Aimee for your incredible leadership and for sharing these exciting pockets of practice that are happening across the United States. I see the Q&A is very active. We're going to try our best to get to as many as possible. And please, we welcome you to continue dropping in your questions. I see a lot of— I think a lot of people are excited to hear about this work and are wondering kind of both if it's available elsewhere and what folks on the call can do if they want to replicate this work. And I know I saw Aimee that you've been multitasking and already answered some of these questions. But as policy folks, we love talking about replication and expansion of what works. And I'd love for both Aimee and Melissa to speak to just candidly to both the challenges related to replication and opportunities. I think you both spoke also to the importance of co-locating or partnering with trusted organizations. How can partners on this call be thinking about how to make that happen? And what, what stories can you share about what works? Maybe we can start with Aimee and then pass to Melissa.

[[FOR THE Q&A PORTION OF THE TRANSCRIPT, SPEAKERS ARE NOT IDENTIFIED BY NAME. PLEASE SEE THE RECORDING TO IDENTIFY SPEAKERS.]]

[00:48:35.01] - Speaker 3

I think I was very fortunate in Chicago to have the open collaboration with the Illinois State Board of Education, right? And to be able to work with a network of refugee resettlement programs. You know, now that, I think that's always the issue. Who's going to be the funder that's gonna support the staffing and the training of a program like this to make sure that it's sustainable? And so this goes hand in hand with Maki, what you had said, that we need empirical evidence. I remember when I approached Illinois State Board of Ed, they had said, we'd never done this before. And so with the ask to, can you help me implement this program, pilot it, Could you also give me research funds to study it? And I think the more that we get creative with finding funding to be able to nest co-locate programs where immigrants and refugees are already accessing those services, if we can get creative with launching those programs, but also have the foresight to study those programs, I think that builds the evidence to ensure that they, there are more people that would be willing to fund this, whether it's public or private dollars, we need the funding to make sure that this is not a one-year program, but it's something that sustains over time.

[00:49:41.07] - Speaker 3

And I'm so proud that with the evidence and the hard work and just the demonstration that this refugee home visiting program works at RefugeeOne, it's been in existence since 2016, and it only continues to grow with greater diversity of refugee home visitors to match the arriving groups that are coming.

[00:50:02.17] - Speaker 4

I can speak to some of the challenges with expansion, scaling, and implementation of Healthy Steps broadly and specifically for this population. I think our two greatest challenges, similar to what Aimee was just saying, is sustainability. So really thinking about who benefits, what, what agencies and organizations benefit from the implementation of a model like Healthy Steps. And that is most notably the healthcare system, but also other systems, child welfare, workforce, education. All of those systems benefit from early identification and, and response to early childhood infant mental health needs and health promotion in that arena in the context of primary care. It is really challenging to sort of advocate for investments across multiple departments or systems in, in a setting that, that most obviously benefits healthcare. It's also challenging to, uh, for healthcare in and of itself to invest in programs that, um, have an upfront cost that often take years to demonstrate the long-term returns on investment. So I think ongoing conversation, which obviously this has been happening for a long time about the opportunities for large returns on investment, both in the short term, but most importantly in the long term for families and children in the context of, you know, in the context of the healthcare system, particularly in, you know, specifically, and how that broadly benefits the whole system of care throughout the lifespan.

[00:51:49.00] - Speaker 4

Sustainability, I think, is one of the biggest challenges. What feels like is quickly reaching or maybe surpassing that challenge for us in Colorado, and I think this is true across the country, is workforce. There just are not enough early childhood mental health professionals. And there are certainly not enough bicultural, bilingual infant and early childhood mental health professionals. We are pretty lucky in Colorado in our Healthy Steps sites. About a third of our Healthy Steps specialists are bicultural and/or bilingual. And but none of them are former refugees themselves. So we do not have the same opportunity that Aimee has in her program, which is amazing. But, you know, I would love to figure out What is the pathway that we can create for, for these individuals to access the resources that they need to be able to deliver these services, you know, that are so needed and would be even more effective if we could, could resource and support families from within or, you know, individuals to become professionals within the communities that they are, that are represented. That they need to be represented. So those are—

[00:53:11.00] - Speaker 3

I just want to add one addition to just what you said, Melissa. One of the challenges we've seen in trying to cultivate an early childhood workforce that reflects the communities that are arriving is that there are education requirements that sometimes these arrivals don't fit. When I was thinking about some of the requirements in Illinois that were specific to being a home visitor, you had to have an associate's and a a specific degree or a bachelor's degree over time, the strongest home visitors we found were those that never had an opportunity to get an education because they were refugees in camps for over a decade. And so how do we make sure that our workforce development capacity building requirements match the skillset of what we need most to do this work in promoting infant early childhood mental health? That too has to be a policy recommendation and a system infrastructure change we have to attend to.

[00:54:01.13] - Speaker 1

Yeah, thanks so much to you both for those responses. And just because we're short on time, and actually this question does build on what you were speaking to, which is kind of about the tiers of the workforce and kind of what folks can do at every level. There was a question about assessment tools that frontline workers who may not be trained in IECMH can use. There was also some questions about clarifications on what Healthy Steps Specialists are qualified to do, Melissa. So I was wondering if you could integrate that into a response. Response about what does assessment look like at different levels depending on qualification and kind of specialization in IECMH and what's possible across levels?

[00:54:39.02] - Speaker 4

I can answer the question about Healthy Steps and kind of talk about our screening tools. I think the opportunity we have with Healthy Steps is because it is a team-based approach and in the context of, in the context of a of a team-based and a multidisciplinary setting in primary care where the Healthy Steps specialists, if they are not specifically credentialed in mental health, which is, is not technically a requirement, and I'll say more on that in just one second, you have the support of other professionals, medical providers, nurses, home family navigators, other supports with potentially within your clinic. To make sure that families, all of the needs are being met, even if that's not necessarily your responsibility to meet them. So we do, in terms of assessment, lots of screening ages and stages. Some of our, a lot of our sites are using the SWYC now. So really brief screeners rather than more intensive assessments. And then connecting families with other supports outside of our organization, our agencies and clinics. When they need more additional assessment. The Healthy Steps Specialists, the national office does not designate a specific credential or criteria. I will say from my experience, mental health questions will come up as a Healthy Steps Specialist when you're seeing families with a lot of needs.

[00:56:03.21] - Speaker 4

So things like significant maternal or paternal mood, potentially postpartum psychosis, trauma, things like that. It is very helpful to have mental health training. When that is not available, having access to a mental health provider who can provide support when those more acute or significant needs come up so that there can be a multidisciplinary approach to supporting those families, I think has been a strategy that we've used here in Colorado. Aimee, I'll let you.

[00:56:37.03] - Speaker 3

Yeah, I mean, to build on this, I think looking at the continuum of mental health supports, I tend to go with a public health approach to thinking about mental health promotion and mental crisis prevention. To Melissa's point, we don't have a multilingual, multicultural mental health workforce to support the needs of what we are already seeing in the field now. We are coming out of a mental health pandemic because of COVID And when we think about the specialized care for the birth to 5 space, there are even less providers. And so it goes back to this idea of having a diverse body of professionals that can promote mental health with universal strategies that support mental wellness. So being able to talk about what is infant early childhood mental health and everyone having cross-cutting language to know what to look for. You know, the second tier of a public health lens is small group intervention. So we're not looking for clinical providers but spaces like accompaniment programs, like home visiting, where it is community-based and it gives an opportunity to have a deeper touchpoint on what families need to promote infant early childhood mental health. And what ultimately this structure does is it narrows the total number of children that would need that level of specialized care.

[00:57:49.13] - Speaker 3

It makes sure that the children who need it most are seen, identified, and they get to the right services. And so this is how we can think about kind of mental health models that we can all exist with our different levels of experience in our different settings to ensure that everyone has the baseline information and we narrow the total number of people to the services that are limited, but who need it most.

[00:58:14.13] - Speaker 1

Thank you so much. And I'm aware that we're running short on time. I did want to take one more question. Actually, I'm going to kind of put a bunch of questions together because there are questions both about language access as well as just the complexity of the healthcare system. And relatedly, there's been someone asking about actually the accessibility of pediatrics specifically for immigrant and refugee populations. And I just wanted to point quickly to a separate thread of work that we have that's very much relevant on language access and the need to improve systems, early childhood systems as a whole, and how many opportunities there are to do that and advocate for that at the federal and state levels where language access is a civil rights requirement, but there's very little accountability. And so if everyone on this call could be just aware of, and I will drop a link to the language access report in the chat because I think providing that home language support and providing just basic accessibility is so critical. I also wanted to give Lillie a chance to speak to partnerships that have happened in the past between refugee resettlement and mainstream early childhood services.

[00:59:16.18] - Speaker 1

And then I wanted to give Melissa and Aimee just a last chance, last word about navigating systems and in particular access to pediatric services.

[00:59:27.04] - Speaker 2

Sure. Thanks, Maki. And I'll weigh in quickly because I know we're, we're short on time, but I do feel like the partnerships between resettlement agencies and, uh, childcare facilities, federal childcare like Head Start, Early Head Start that is not status restricted is a wonderful partnership to build. And I mean, naturally you run into the, like, you know, the same barriers that other populations run into where there's limited bandwidth, there are waitlists that affect everybody. But I do think that those partnerships are worthwhile and worth nurturing. And I think they've been on the radar of resettlement agencies for a long time. And so I think it speaks to the possibility of future partnerships with other early childhood providers that are not super subject to these really rigid eligibility restrictions.

[01:00:14.06] - Speaker 4

Aimee, do you want us— do you want me to jump in?

[01:00:17.01] - Speaker 3

You could jump in.

[01:00:18.02] - Speaker 4

Okay. I would just say quickly about the pediatric access for this population or these populations, and that is real that some families are not even aware, depending on what kind of support that they've received or information or if they are comfortable even accessing health insurance. And so I think a couple of things I will say, I think that is why we need to resource the entire system of care, that primary care needs to be a component of that, but it can't be the only component any more than any one thing can be the only component that they're, you know, home visiting, Early Head Start, you know, all of these different resources and that we provide messaging to communities. I know that for our, our popular clinics that have a high refugee and immigrant population, which we do in my particular clinic, a lot of it is word of mouth within the community that this is a safe place to go, that your needs will be met. And so when you provide really high quality care, families are more likely to continue to come. We can get them in the door in the first place and then communicate to their their close community and close family members and neighbors about that this is a safe place to come and that their needs will be met.

[01:01:36.03] - Speaker 4

So that's— those are my thoughts about that.

[01:01:39.06] - Speaker 3

And building off on that, I think that there's an opportunity whenever we have webinars like this because then we get to discuss what is actually happening on the ground. It gives us ideas that we're not operating in silos and there are different states different communities that are doing innovative work to really bridge a lot of the miscommunication and the gaps in information. I'm excited to see what happens in Illinois because there's a lot of conversation around an early childhood division in which under one roof we're gonna have Head Start talking to home visiting, talking to pediatric care. And if that is a model and infrastructure that works, this is something that then can again be replicated in other spaces. And so it all comes down to communication. How do we make sure that the conversations we have around leadership and around program service providers, that it trickles down to the populations that need to hear it most and creating that safe space to talk about who's the trusted partner and where can you go. That's part of everyone's responsibility. And so we all should hold that.

[01:02:39.20] - Speaker 1

Well, these are perfect words to end on. I'm so sorry that we're out of time. This was such a generative conversation. Thank you again to everyone for joining us. I'm so sorry for those questions that have not yet been answered. We will do our best to follow up with those that we weren't able to get to. Please also do return to the report available on the website, which speaks to everything we addressed in greater detail. An audio and a video recording of the webinar will be available in the coming days on the event website. Any reporters on the call can contact Michelle Mittelstadt, our Director of Communications, at [email protected] with any questions. Thanks again, everyone, and especially to our speakers for your inspiring work and your wonderful presentations, and take care, everyone.