PURPOSE:

This Information Memorandum (IM) highlights the Head Start Program Performance Standards and related strategies for integrating mental health supports across all Head Start programs.

BACKGROUND:

Head Start programs, including preschool programs, Early Head Start programs, Migrant and Seasonal programs, and American Indian and Alaska Native programs, have a long history of providing comprehensive services alongside early education services. They support a program-wide culture that promotes children’s mental health and social and emotional well-being. Children’s mental health is foundational for family well-being, children’s overall healthy development, and long-term success.¹ In recent years, Head Start programs have called for guidance on how to be more intentional in integrating mental health supports into programs. These calls stem from a reported rise in behavioral and developmental concerns, higher rates of staff turnover, and limited availability of specialized mental health services. This IM provides evidence-informed mental health strategies and associated resources that can help address these challenges as part of a renewed effort across federal early childhood funding agencies to integrate mental health supports into programs.

To integrate mental health supports effectively into Head Start programs, it is important to first understand and destigmatize what is meant by “mental health.” Young children’s mental health, often referred to as early childhood mental health (ECMH), is not mental illness. Rather, it is the same as social and emotional development and well-being. It is a child’s capacity to express and regulate emotions, form trusting relationships, explore, and learn — all in the cultural context of family and community. ECMH approaches should support every child’s development of social and emotional skills, in addition to providing specialized supports for the up to 20 percent of children under the age of 5 who experience social and emotional difficulties.²

Strengthening the focus on mental health is particularly appropriate given the Head Start program's mission to serve the most vulnerable children and families and break the cycle of poverty. Individuals living in high-poverty neighborhoods often have less access to high-quality resources and supports compared to individuals living in low-poverty neighborhoods, and are more likely to have worse mental health outcomes as a result.³ Furthermore, Black, Indigenous, and People of Color (BIPOC) families⁴ and families in remote or rural areas have less access to mental health and substance use services.⁵ BIPOC families, including families in tribal communities, are disproportionately affected by chronic stress resulting from structural racism and historical trauma, which further narrows access to services they can trust.⁶

Head Start programs play a vital role in addressing ECMH and reducing disparities in ECMH, because they focus on the whole child as well as partner with families and communities. Family-focused efforts in particular ensure children’s mental health continues to be supported in the long-term, after children transition to kindergarten. Many Head Start programs have already adopted diverse strategies to address ECMH. Programs support family well-being and staff-wellness, which ensures caregivers are well equipped to support ECMH. They directly support the child by strengthening relationships with responsive caregivers, such as parents and early childhood staff, which is the foundation of ECMH. They provide stable, nurturing environments in which children can safely learn and practice social and emotional skills, and partner with families to do the same at home. Head Start staff build trusting relationships with families and partner within the community to identify and leverage resources. These steps make it more likely that mental health supports will meet the needs of families and make a difference.

GUIDANCE:

Although there are many ways mental health can be supported in Head Start programs, it is important for programs to develop a comprehensive, integrated early childhood mental health approach that promotes child and adult mental health, prevents concerns from developing, and supports early identification and referrals for treatment when needed. Using a continuum⁷ of mental health supports ensures every child and family receives the appropriate level of care. This continuum includes:

1. Mental health promotion – An approach aimed at strengthening positive aspects of mental health and well-being and is focused on setting children and families up for success. 
2. Prevention services and supports – An approach aimed at reducing the likelihood of future disorders in the general population or for people who are identified as at risk of a disorder.
3. Access to mental health treatment – Interventions are delivered to people who continue to be at risk after engaging in prevention services or have been diagnosed with a mental disorder.

The Office of Head Start (OHS) continues to strongly encourage grant recipients to use quality improvement funds available to all Head Start, Early Head Start, American Indian and Alaska Native Head Start, Migrant and Seasonal Head Start, and Early Head Start-Child Care Partnership grant recipients to support these strategies and invest in mental health supports across roles and program service areas. Suggestions of allowable uses for quality improvement funds as specified in the Head Start Act can be found in the FY 2023 Head Start Funding Increase Program Instruction.

For Head Start State Collaboration Offices and recipients closely working with states, it may be of interest to review related program guidance.

Strategies and Recommendations to Support Mental Health

These strategies support program quality and describe resources that can help programs comply with applicable Head Start Program Performance Standards.

Increase Mental Health Promotion

1. A focus on social determinants of health, or the conditions in which individuals are born, grow, live, work, and age, can lead to better mental health outcomes and prevent future mental illness. To promote social conditions that support family well-being, such as family safety, health, and economic stability, programs are encouraged to develop innovative two-generation approaches that leverage community partnerships and address prevalent needs of children and families (45 CFR §1302.50(a–b)). To achieve this, programs can:
   • Create authentic partnerships with families using the Building Partnerships with Families Series as a guide. Programs can support family mental health and well-being by using the family assessment and partnership process to help families with their biggest life stressors. 
   • Update the program’s intake process with families to include targeted discussions on mental health, such as the families’ perceptions about mental health and addressing potential stigma. Include information on mental health supports in the program, such as mental health consultation services and resources and supports available in the community.
   • Establish formal and informal check-ins with families with the intent to support family mental health. For example, build in time during parent-teacher conferences to discuss how families are doing, create a drop-box for parents to discreetly communicate their needs to staff, and devote time in every parent meeting to wellness activities.
   • Invite the mental health consultant to introduce themselves at program events, such as an “Open House” to explain the Head Start program’s commitment to supporting mental health. This is an opportunity to familiarize parents with the mental health services available to them, including the role of the mental health consultant and how consultation is used throughout the program. 
2. To promote family well-being, programs must collaborate with parents by providing mental health education support services. These services include opportunities for parents to learn about healthy pregnancy and postpartum care that encompasses mental health and substance use treatment options (45 CFR §1302.46(a)). To achieve this, programs can:
   • Offer opportunities for families to connect to talk about their child’s development, how they are coping with potential stressors, and what resources they are using. Create a parent group, either virtually or in person, that serves as a space for parents to express their emotions, thoughts, and feelings. For guidance on facilitating this activity, refer to Leading Online Parent Meetings and Groups.
   • Provide training and opportunities for parents to learn about children’s health, well-being, and mental health (i.e., in person trainings, virtual trainings, resources/handouts, etc.), as well as developing safe, stable, and nurturing relationships and environments. For example:
     1. Use the mental health consultant to provide group wellness sessions with parents. In these sessions include information on resources in the community and how to access these resources. 
     2. Invite speakers from mental health and substance use agencies to give talks about mental health and substance use.
   • Regularly check in with families about providing supports for their own mental health and well-being, such as education materials on reducing stress and understanding depression.
   • For pregnant women and expectant families enrolled in Early Head Start services, include a mental wellness check during the newborn visit that a program must provide to each mother and baby within two weeks after the infant’s birth (45 CFR §1302.80(d)). These mental wellness checks are geared towards the parent or family members caring for the child and can be incorporated into a daily health check. Consider incorporating screenings for adult mental health, including depression, and substance use, with appropriate guidance from a mental health professional. 
3. To promote staff well-being, programs must make mental health and wellness information available to staff regarding issues that may affect their job performance and must provide staff with regularly scheduled opportunities to learn about mental health, wellness, and health education (45 CFR §1302.93(b)). To achieve this, programs can:
   • Implement identified policies, procedures, and strategies to support staff wellness that are informed by program data, such as those described in ACF-IM-HS-21-05 Supporting the Wellness of All Staff in the Head Start Workforce. It is important to gather feedback from staff on their well-being and job satisfaction, as well as wellness strategies, to determine if refinements or improvements are needed.
   • Provide program leaders with foundational training in supporting workforce mental health such as through the National Child Traumatic Stress Network (NTCSN The NTCSN offers resources and trainings on a wide range of topics, including strategies to prevent, recognize and address secondary traumatic stress, which may be experienced by Head Start staff caring for children affected by trauma. 
   • Consider establishing communities of practice or reflective supervision groups that help directors and managers focus on creating safe environments and communications that convey to staff that it is safe to disclose and receive support if and when they experience mental health challenges.
   • Promote employee assistance services and build a culture to address the stigma of seeking help for mental health reasons. Raise employee awareness around free or low-cost mental health supports available, such as benefits included in health insurance plans.
4. To promote child well-being, a program must ensure staff, consultants, contractors, and volunteers implement positive strategies to support children’s well-being (45 CFR §1302.90(c)(i)). To facilitate implementation of positive strategies, programs can:
   • Train staff, consultants, contractors, and volunteers to have basic knowledge of developmentally appropriate strategies to support positive behaviors. Since developmental expectations and appropriate strategies may differ depending on a child’s age and developmental skills, staff working with preschool-age children, may still benefit from a basic understanding of how to support infants and toddlers.
   • Ensure staff understand that following children’s lead in structured play activities is an impactful way to understand children’s developmental skills, identify and offer positive attention to their strengths, and practice self-regulation skills in a controlled environment. 
   • Make sure learning environments are designed to support children’s self-regulation. This could include creating “cozy spaces” that are clearly visible to adult supervision where children can go if they are feeling overwhelmed. Similarly, spaces can be created with activities or sensory materials as places to express energy. These types of spaces are designed so that teachers can still observe the child or children who are in them, while also providing them the needed supports to self-regulate.
   • Partner with families to understand the development, communication style, strengths, and temperament of each child in order to establish predictable routines, transition strategies, and developmentally appropriate behavioral expectations for children in the program. 

Increase Prevention Services and Supports

5. To support children’s ongoing social and emotional development, programs must provide supports for effective classroom management and positive learning environments; supportive teacher practices; and strategies for supporting children with challenging behaviors and other social, emotional, and mental health concerns (45 CFR §1302.45(a)). To achieve this, programs can:
   • Implement an all-hands-on deck approach by creating a multidisciplinary team that works together in your program to support children’s mental health. This team can be comprised of individuals that already work with the child or family across disciplines. The benefit of having a team of professionals with multiple perspectives (i.e., mental health, early childhood, special education, family service, health, nutrition, etc.) is that it ensures the most comprehensive approach to support the needs of a child and family. 
     • For example, consider ways to integrate prevention-focused approaches such as the Pyramid Model with mental health supports such as mental health consultation. 
   • Seek direct guidance from a mental health or child development professional to ensure that findings from developmental screening and assessment required in 45 CFR §1302.33, including social and emotional screenings, are used when making a referral to determine if the child is eligible for services through IDEA or section 504 of the Rehabilitation Act. While programs wait for an eligibility evaluation and possible services, programs can consider an individualized approach to support positive behaviors and teach new skills. 
   • Review your program’s educational curriculum to ensure it offers appropriate social and emotional learning opportunities, including intentionally planned learning experiences to help practice self-regulation skills. If you notice that many children in the group need social and emotional development support, spend some time intentionally embedding more of the experiences and activities from your curriculum that support these skills. Work these activities and supports into your daily routines and revisit them as needed to ensure children are developing skills in this area.
   • Implement a systems-level approach for adult regulation such as the “Tap-In/Tap-Out” system⁸ when an education staff member is feeling frustrated, overwhelmed, or otherwise dysregulated. This strategy allows for education staff to engage another staff member from a predetermined list to “tap-in” and cover the class. The education staff member can then “tap-out” and engage in strategies for accessing a calm state before returning to the learning environment.
6. Infant and early childhood mental health consultation (IECMHC) is a prevention-based approach. Mental health consultants work with Head Start leaders, staff, and families to support children’s healthy social and emotional development. Grant recipients have shared that it can be challenging to obtain mental health consultants, particularly in rural areas. A few strategies for building mental health consultation access include:
   • Encourage existing staff to use educational benefits, such as tuition and fee support, to work towards mental health consultant qualifications. These and other strategies are described in ACF-IM-HS-22-06 Strategies to Stabilize the Head Start Workforce.
   • Reach out to mental health organizations and other early childhood programs to identify potential partners for mental health consultation services. For example, ask other local Head Start or early childhood programs, home visiting programs, and state or tribal early care and education offices how they find mental health consultants. Ask local pediatricians, community health clinics, and hospitals where they refer children and adults for mental health services. After identifying possible partners, reach out to orient them to the role of mental health consultation in Head Start programs and explore potential collaborations.
   • Prioritize finding a mental health professional who is familiar with the families in your program or community. Your Head Start program can help them learn about child development, group care, the culture of your program, relevant HSPPS, and IECMHC.
   • Consider implementing approaches such as telehealth or remote consultation, especially in rural areas, while efforts to build capacity for in-person mental health consultation are underway⁹.
   • Consult IECMHC.org’s interactive map of consultants. 
7. To ensure mental health consultants engage in prevention-focused activities, programs must ensure the mental health consultant assists, at a minimum, with the requirements listed in 45 CFR §1302.45(b). To achieve this, programs can:
   • Provide professional development opportunities for staff during onboarding and periodically after. For example, the Foundations of Infant and Early Childhood Mental Health Consultation iPD Course can ensure that all staff understand that IECMHC is a way to grow the capacity of adults to support the child’s social and emotional well-being, rather than a direct intervention or treatment approach.
   • Use the expertise of the mental health consultant at a programmatic level, in addition to consulting at the level of specific children, families and classrooms. For example, the mental health consultant can help program leaders and staff explore strategies for enhancing systems that support staff well-being. They can also help design program-wide policies and procedures related to mental health supports, such as positive discipline or screening and assessment practices. 

Access to Mental Health Services

8. Programs must build community partnerships to facilitate access to additional mental health services as needed (45 CFR §§1302.45(a)(4), 1302.53(a)(2), 1302.80(c)). To achieve this, programs can:
   • Consult with your Health Services Advisory Committee on local opportunities and potential partnerships. Identify grant funds available in your local community that are designated to support early childhood mental health. For example:
     1. Partner with local Certified Community Behavioral Health Clinics (CCBHCs). CCBHCs are designed to ensure access to coordinated comprehensive behavioral health care. CCBHCs are required to serve anyone who requests care for mental health or substance use, including developmentally appropriate care for children and youth, regardless of their ability to pay, place of residence, or age.
     2. Leverage community health workers, family navigators, promotores, and peer specialists to reduce mental health stigma and provide support to families navigating mental health systems and other systems that address social determinants of health. 
   • Use resources that offer expertise in culturally grounded mental health practices, such as partnering with tribal healers to connect families to traditional ways of healing. 
   • Build partnerships with local colleges and universities that may provide sliding scale mental health services through their mental health training clinics. A sliding scale is a flexible fee structure or payment system that asks a client to pay based on their ability to do so. 
   • Facilitate access to community enrichment activities that can both protect and promote child and family mental health (i.e., sporting activities, cultural events, religious organizations, farmers’ markets, and play groups).
   • Assess barriers to obtaining mental health services and provide supports based on this assessment to facilitate access. Examples could include providing transportation from the program to clinics or providing families with private spaces equipped with appropriate technology to access tele-mental health services. 

These evidence-informed mental health strategies can support Head Start programs in intentionally integrating mental health supports across their program. They can address challenges programs face such as behavioral and developmental concerns, staff burnout, and the limited availability of specialized mental health services. The accompanying appendix includes more specific resources to support these recommendations. 

OHS will continue to work with programs to support the mental health of children, families, and staff in Head Start programs. Please direct any questions about the content of this IM to your OHS regional office.

Thank you for all you do on behalf of children and families.

Sincerely,

/ Khari M. Garvin/

Khari M. Garvin
Director
Office of Head Start