Introduction

As many as 30 % of children in low-income communities display signs of emotional disturbance or problematic behavior that interferes with their ability to learn in the classroom (Feil et al. 2000). These problems are on the rise and strongly predict later delinquency, aggression, antisocial behavior, and substance abuse (McCabe and Frede 2007). However, a large portion of young children with emotional or behavioral problems go untreated and unassisted. Despite available screenings and treatments, very few preschoolers who meet criteria for a psychiatric disorder are identified, referred for an evaluation, or receive treatment. Less than half of children with developmental delays and mental health problems are identified before they enter kindergarten (Glascoe 2000). Lavigne et al. (1998) found that only one quarter of preschoolers identified with mental health issues were referred for treatment. Making services available to families would certainly improve treatment rates. However, some would likely remain unserved, due to the stigma surrounding mental health services. This research presents findings from a study of a preschool mental health access initiative regarding engagement strategies and experiences from the perspective of clinicians, teachers, and parents.

It is estimated that one in five children and adolescents have a mental health disorder (U.S. Department of Health and Human Services 1999). Estimates of children exhibiting emotional disturbance or behavior significant enough to disrupt their functioning at home, school, and in the community vary from as much as 3–17 % in the general population (Achenback and Edelbrock 1981; Centers for Disease Control and Prevention, 2013; Costello et al. 1998; Qi and Kaiser 2003) to as much as 30 % in low-income communities (Feil et al. 2000). Additionally, research suggests that 10 % of the school-aged population may meet criteria for a mental health diagnosis (Angold et al. 1999). Recent surveillance of this issue suggests an increase in diagnosis and treatment for mental health disorders for school-aged children (Centers for Disease Control and Prevention 2013). These issues raise questions such as: How do we begin to provide mental health services to preschool children?, How do we engage parents and the local community to help provide these services?, and What are some of the barriers and challenges to service provision for this population?

Literature Review

Preschool-Based Mental Health Strategies

Early intervention programs, such as high quality preschool, have demonstrated strong results for children at risk of intellectual developmental problems, but have been much less successful at addressing social-emotional learning problems that typically co-occur in at risk child populations (Guralnick 2000). Developmental tasks such as understanding social rules, emotion regulation, social cues, and processes relevant to goal development/attainment are critical in early childhood (Guralnick 2000), as are children’s skills related to emotional expression, regulation, and utilization (Denham et al. 2012).

Research underscores the importance of social and emotional competence in early childhood (Blair et al. 2004), and indicates that social-emotional learning is an important aspect of preschool curricula (Bagdi and Vacca 2005). Studies have found that emotional competence in early preschool has long-term implications for social outcomes (Denham et al. 2003), and that a positive relationship between child and teacher correlates with school success (Baker 2006). Further, the ability of children to regulate their emotions was found to be positively associated with their academic success and productivity in the classroom (Graziano et al. 2007), and their understanding of emotions was found to be a predictor of school competence (Garner and Waajid 2008).

Preschools are natural environments for accessing at-risk children and their families (Bagdi and Vacca 2005). It has been suggested that many problems in children’s behavior can be prevented through the use of classroom-based strategies, therefore reducing the need for more expensive interventions (Hemmeter et al. 2006). A number of factors have been found to affect the efficacy of the services. Outcomes of center-based services may be affected by the amount of time the mental health consultant has worked with a center, director support for the services, and staff turnover (Alkon et al. 2003; Alkon and Sokal-Gutierrez 2002). The quality of the preschool program, the cognitive abilities of children in care, and the cultural context of the families and community will also affect the implementation of intervention programs (Hemmeter et al. 2006).

In order to provide these much-needed services to children, families need to engage in mental health services for their children. Brown et al. (2014) found that parents with low socioeconomic status are reluctant to acknowledge and accept the socio-emotional problems of their preschool aged children. Parents felt that there was not enough explanation or advice given about the specific issues and also experienced uncertainty regarding what to expect from behavioral health treatment. In a systematic review of forty studies, Lindsey et al. (2014) identified a number of practices that were most successful in engaging children for mental health services including: setting realistic expectations for clients, assessing barriers to treatment, identifying networks of support, acknowledgement of cultural issues, problem solving, and relationship-rapport building.

Methods

The goal of this study as well as other qualitative research is to expand the understanding and knowledge of one specific subject area (Strauss and Corbin 1998). Qualitative methodology is often conceptualized as the preferred approach to data analysis and research design in situations that seek to understand a particular social phenomenon, to develop theory, and to gather in depth information on a particular subject or topic (Ambert et al. 1995; Rubin and Rubin 1995). Umberson and Slaten (2000) suggest that qualitative methods are useful in research with the purpose of learning more about social context and the meaning of social phenomena. As such, qualitative methodology was identified as the most appropriate way of gathering and analyzing specific data in this research, and for the specified research questions.

Design

In seeking to understand parents’ perceptions and thoughts regarding the provision of services in various programs, the efficacy of services provided, and their levels of satisfaction and dissatisfaction with the services that they received, the research team determined that conducting interviews with parents would allow for the greatest opportunity for parents to provide detailed and specific feedback. As Rubin and Rubin (1995) suggest, “qualitative interviewing explores the shared meanings that people develop in work groups, ethnic neighborhoods, recreational centers, hospitals, churches, and any other place where people interact” (p. 8).

Similarly, through the use of focus groups, the researchers were able gain valuable information and feedback from a significant number of people at a time, and have the benefit of hearing their specific experiences and perspectives. Berg (2001) underscores the importance of this interaction, “focus groups provide a means for assessing intentionally created conversations about research topics or problems…Researchers can observe session participants interacting and sharing specific attitudes and experiences, and they can explore these issues” (p. 115). In this way, including focus groups in the design of this study was instrumental in allowing individuals to describe their “shared meaning” as it relates to their own experiences and perspectives as clinicians and teachers working within this Initiative.

Focus Groups

The researchers facilitated focus groups with clinicians from all three programs who participated in the Initiative. Three focus groups with teachers were held at each individual program. All participants in the focus groups signed informed consent forms, were given one copy to keep for their personal records, and were audio taped. Data from the focus groups were transcribed verbatim.

Parent Interviews

Prior to the initiation of the parent interviews, and as part of the IRB documentation, an interview guide was developed by the research team in order to elicit information from parents about the program and evaluative components. All parents who participated in the interviews signed informed consent forms, were given one for their personal records, and were audio taped. Data from the parent interviews were transcribed verbatim.

Sample

The participants in this study included parents, teachers and clinicians who had worked or participated in three urban preschool programs in a Northeastern state. The teacher and clinician focus groups included current employees at each of the three programs. The sample for this study consisted of participants from various socio-economic, racial, ethnic, and educational backgrounds. Teachers and clinicians were contacted via email from their respective program several weeks prior to the scheduled date, and were invited to participate in a focus group. Incentives were offered for some of the focus group participants, depending upon available funds through each individual program.

Data collection

The focus groups for this study were conducted at the provider agencies and preschools. Parent interviews were conducted in person at the child’s school, parent’s home, or the provider agency, based on the parent’s preference. Data collection for this study occurred over the course of a four-month time frame, during which the research team conducted one clinician focus group (with clinicians from all three sites), three teacher focus groups (one at each site), and twelve parent interviews (four from each site).

Data analysis

Analysis of the data was an ongoing process throughout the study, as the researchers reviewed transcripts, wrote notes, and identified themes. Upon having completed the focus groups and interviews, the researchers transcribed the recordings verbatim.

The researchers utilized the strategies described in Basics of qualitative research: Techniques and procedures for grounded theory (1998) by Strauss and Corbin. They suggest that microanalysis be an integral aspect of data analysis and describe it as, “the detailed line-by-line analysis necessary at the beginning of a study to generate initial categories (with their properties and dimensions) and to suggest relationships among categories; a combination of open and axial coding” (p. 57). Further, they suggest that during open coding, the researcher breaks down the data into various parts, and then closely examines the data for similarities and differences and that through this process, the qualitative researcher begins to uncover various themes that emerge from the data. During the process of open coding, initial concepts were developed and explored, and then compared to other data as they were collected. The researchers also employed the use of line-by-line analysis during open coding, described by Strauss and Corbin (1998) as a process that involves analyzing data phrase by phrase or word by word. In using this strategy, the researchers were able to develop categories and identify themes in the data.

Results

Themes and findings that emerged from the study are described below.

Importance of Collaboration Between Clinicians and Teachers

Clinicians discussed the role of the teachers in the process of engaging children and families, and indicated that in some cases, clinicians provide feedback about a child to the teacher, and offer specific suggestions. However, in some cases clinicians reported that teachers did not follow up. One person explained, “after so many sessions you go to the classroom to do observations and you see in some way how the teacher handled certain situations then you think to yourself ‘oh okay, we went over this, what happened?’.”

Another clinician described the ways in which they work to engage the teachers to help increase awareness of the ways children may be affected by their school experience.

“We try to work with the teachers to let them know this child has challenging behaviors, but that their whole experience with school is going to start with their name always being the name being called. They are always the one who is being told ‘No, stop, don’t do this, don’t do that. You are doing that wrong’. And so kind of shifting that focus and really going to change the way that child views themselves as a student for the rest of their school experience. Sometimes that is hard for teachers to understand, because it is often those children in the class that are disrupting the activities. They have to constantly be aware of shifting the focus from the negative to the positive.”

Teachers at all sites report that the program was most successful when all the parts of the team are working together to share information. One of the teachers recalled the importance of good communication with the clinicians. She described a specific example, “the good thing about it was that the therapist interacted with teachers, so I had the opportunity to sit down and find out what they were doing at the time, to collect information regarding whether or not the child was actually improving over the course of the year…I thought that was very beneficial to both myself and the therapist that we shared information”.

Parental Engagement

The clinicians discussed challenges associated with getting parents involved in the program and the provision of mental health services, and noted that, in some cases, one of the challenges is that parents don’t know what to expect. One clinician explained that much of what they do includes “educating parents about the process and managing their expectations and also remembering to put a lot of the onus on them. They have to do a lot of the work themselves. So it is supporting them and the work they do at home.” Another clinician described a different challenge as it relates to the involvement of parents, “I think parent engagement is a really difficult part because we are coming to them. They are not coming to us for services.”

Another clinician described the ways in which gender and cultural issues can affect their roles and acceptance by the parent, “I think culture also plays an important role too. At this point, what I notice working with fathers, is that they have a hard time receiving suggestions from a female, especially in cases where I am younger than him.”

Importance of Acceptance/Support from the Community

The clinicians also described the influence of the local community on the success of the program and the outcomes of their work, and they recalled their initial efforts in getting the community “on board” with the program. One explained, “the first thing was dealing with resistance from the community because they didn’t want to be associated with mental health issues, so that took a number of meetings with the parents to have different people that they trust say positive things about the program. And then over time that began to get better.”

Clinicians described the importance of other key members of the community who assisted them in the process of reaching the parents, “some of the family workers had deep roots in the community so people came up to one of the family workers in the beauty shop or store and said ‘I need to talk to somebody’…They would trust the family workers and they would trust the director and the priest.”

Another respondent described the process of enlisting community support, “in the beginning it was having the clinicians be very present in the community, as much as we could be. So we were in the preschools not just getting familiar with the teachers and staff, but trying to be there on the first day of school and ‘Back to School’ night, introducing ourselves. We have a Community Fair and we try to attend other types of events within the preschools so they are not only hearing about the program from people they trust, but they are also learning to trust the clinicians from seeing us around and knowing we are dedicated to the program.”

Clinicians’ Approaches to Engaging the Family

The participants described the many ways in which they work with the families and children who participate in their programs. One person emphasized their process in engaging the parent(s), “I think focusing on the strengths of the family [is important]. Maybe at this time the parenting skills of the family might not be working in the ways that the parent is disciplining the child. But because you are dealing with A and B and C stressors it has been hard for the parent so [we try to take the perspective of] ‘let’s focus on what you can do from now on’.” Clinicians also described other roles they have in working with the family including educating parents on psycho-educational issues and healthy development.

The clinicians indicated that they work to empower families by emphasizing that parents have choices regarding their child and his or her participation in the program. “Sometimes I tell them, ‘you don’t have to do this, but these are other things the child needs’”. And some clinicians explained that they will check back with parents and follow up at a later time. “So I give them the option that they can discontinue if they don’t feel the child is benefiting, so they have that option open so they don’t feel pressured. And so they don’t feel that I am the white lady who likes to label the child. So that has helped in giving them the option and I will check back with them. And if they don’t feel they are happy, then they can exit.” Another person echoed that sentiment as well, “yes I think it is very important to have parents feel there is a choice. That is an important aspect of empowering them.”

Collaboration with Teachers to Engage the Parents

Clinicians described the process through which their interaction with the teacher often manifests in a referral to the program. Participants reflected on the various approaches they implemented in order to engage parents’ participation in the program. “Usually what we like to do is speak with the teacher about it first and have the teacher approach the parent. That is because the parent usually has a little more exposure to the teacher on a daily basis. So if we call the parent out of the blue and say ‘hi this is so and you may have never heard of me before and now I am going to…’—so we like to have the teacher approach the parent. And then from there we call the parent to have them come in for a meeting to discuss available services.”

Processes Through Which Parents Experienced Engagement Efforts

Parents described the many ways in which clinicians were successful in engaging them in the program. A number of parents discussed characteristics of the clinicians and features of the program itself, which encouraged their engagement experiences. Parents specifically appreciated that clinicians were flexible, that they were forthcoming with information about their child, and that they kept them updated on their child’s progress in treatment. Some parents described the ways that the clinician would engage them in the treatment process. One parent explained that the clinician would send notes home with her child to keep her informed of his progress, and stated that the clinician was also available by phone, which she found to be very helpful. Another parent reported on the program and site itself, in saying that the staff at the program, “were willing to be helpful, [when I] called, they were flexible”. Another parent said, “I never had any problems with trying to reach out to the (clinician) or getting information. The (clinician) kept me updated very well”.

Discussion

Increasing Comfort Levels in Seeking Treatment

The results from focus groups and interviews indicate that there were positive outcomes related to parental engagement. The programs succeeded in helping parents and guardians of children needing early childhood mental health, behavioral and/or developmental health services to feel more confident in seeking services. Several key findings in this area emerged from the focus groups and interviews. Parents described their increased comfort in seeking out mental health services, and sometimes a sense of relief when their child was ultimately able to be helped and treated. These findings are consistent with the literature on preschool mental health programs which suggest that parent engagement is a critical treatment component (Burns et al. 1999).

Respondents indicated that much thought went into presenting the program to parents. Clinicians reported that they often asked a family worker, who was already familiar with the family, to introduce the program to the parents and to arrange an initial meeting with the clinician. This approach, the clinicians felt, was most successful in encouraging parents to consent to their child’s participation in the program. Clinicians identified several challenges to improving the comfort level of parents and engaging them in services for their child. First, the large (and growing) number of immigrant families in this region requires unique sensitivity to cultural issues around mental health, family roles, and help-seeking behavior. Second, clinicians found balancing their role as a mandated reporter of child maltreatment with the need to build a rapport with families was often a challenge because some parents commonly engaged in discipline practices that were illegal or contra-indicated for a child’s long term treatment and well-being.

Parents who participated in interviews described many efforts which were made to encourage their engagement with the program. In particular, parents cited the availability of clinicians and regular communication with clinicians as important factors in their engagement with the program. Parents also appreciated the many opportunities provided directly to them, such as parenting workshops, music and infant classes, referrals to other services and, in some cases, individual counseling for the parent. Further, parents reported that their engagement in the program was facilitated by the impact it had on their children. All parent respondents reported positive changes in their children’s behavior resulting from the services they had received. They also reported that they were better able to cope with their child’s behavior and, often, felt less stress in their lives as a result.

Finally, parents who were interviewed consistently reported positive changes in their children’s behavior both at school and at home. Parents linked these changes to their child’s participation in the program and the receipt of mental health services. Specifically, parents indicated that their children were more adept in expressing their feelings, better able to handle their emotions, interact more appropriately with other children, and were more engaged in school and academic endeavors.

Garnering Community Support

Study participants reported that garnering community-wide support for preschool mental health services was a challenging aspect of the project but was critical to its success. Clinicians, teachers, and parents all highlighted the importance of reducing stigma about mental health issues in general and increasing knowledge about the need for early childhood services in particular. Clinicians described their efforts to develop support from schools and communities by helping them to understand how mental health services could assist both students with behavioral issues (by reducing problematic behaviors) and other students (by reducing disruptions and creating a more learning-friendly environment). Clinicians felt that having early support from teachers and other school professionals paved the way to introducing the program to parents successfully. Because parents often had longer-term relationships with family workers and teachers, clinicians often relied on these professionals to introduce the program to parents.

Increasing Availability of Mental Health Services

Responses from parents, clinicians, and teachers suggest that the program reached an at-risk population for whom services had previously not been available or easily accessed. Prior to the Initiative, children were removed from school and transported to a local clinic for mental health services. Participants reported that this practice reduced the amount of time children spent in the classroom and, according to some respondents, was a traumatic experience for young children.

Factors identified in the literature as contributing to the risk of challenging behaviors and mental health concerns in preschool students include poverty (McLoyd 1998), parental stress related to lower-paying jobs (Jackson et al. 2000), parental divorce (Strohschein 2005), exposure to traumatic events or violence (Berkowitz 2003), and unstable living conditions (Cavanagh and Huston 2006). All of these variables were discussed by parents, teachers and clinicians in this study as factors that have contributed to difficulties in families with subsequent effects on children.

While programs collaborated to varying extents with existing school services such as the Preschool Intervention and Referral Team (PIRT) and Child Study teams, school professionals generally felt that their work enhanced, but did not duplicate, available services. In particular, teachers and clinicians felt that children-in-need could access Initiative services much more quickly than they could access services offered by a school district or other provider.

Most parents interviewed highlighted the convenience of having mental health services available at or through their child’s preschool. Several reported previously seeking mental health services for their children and expressed disappointment with the options available to them in the community. They felt that the Initiative removed many of the barriers they had previously experienced—including high costs, inconvenient locations, and excessive waiting times.

Benefits of Community-Based Agencies

Several participants underscored that children and parents benefited from receiving services from community-based agencies. Some teachers observed that parents may have a negative attitude toward schools and educators based on their own educational experiences. Such attitudes may be exacerbated by concerns about having their child “classified” or “labeled” at an early age. These educators felt that parents were more receptive to services offered by a community-based agency than to services offered by the school district.

Limitations and Recommendations

The purpose of qualitative research is to describe the particular in considerable detail rather than to generalize from a sample to the larger population. Thus, these findings are specific to the group of people studied. Therefore, common themes identified in this sample may not be considered to be “essential” aspects of future programs of this kind. Still, this study highlights the benefits of embedding mental health services in the school setting, including early identification, reducing physical barriers to access, improving utilization by breaking down the stigma and improving social support for service use, and improving ecological/systems consistency in addressing child mental health problems.

Considerable funding has been allocated to developing local and large scale efforts to embed mental health services in preschool environments over the past 10 years. According to Green et al. (2006) a number of states, including Colorado, Connecticut, Maryland, and Oregon, as well as regions of Ohio and California, have invested public and private funding in mental health consultation services. Additionally, Head Start programs are required to provide mental health consultation in their centers (Green et al. 2006). Multiple professions have called for their members to attend to the need for mental health consultation in child care centers, including school psychologists to assist with the attainment of social-emotional skills necessary for kindergarten readiness (Hojnoski and Missall 2006). Research on the implementation of preschool based mental health services has primarily focused on four aspects of service delivery; categorization of the various services offered, challenges to implementation, reduction of behavioral problems in children, and improvement in teacher or parent practices/knowledge. This study makes a contribution to the literature by focusing on an important aspect of implementation; engaging parents, teachers, and the community in addressing young children’s mental health problems early on.

Due to the limited resources of the mental health delivery system for addressing the needs of young children, universal screening procedures in education settings may be an effective and cost efficient means of identifying children most in need of intervention (Essex et al. 2009). Early screening of childhood mental health problems can reliably predict problems in later years (Essex et al. 2009). This project facilitated early screening by engaging teachers, parents, other important early childhood staff, and community-based programs in identifying and referring children for services.

This study, however, suggests that early identification and access may not be sufficient to ensure utilization. Stigma is a considerable barrier to the use of mental health services. Further, individual approaches to addressing child mental health are not likely to be as effective as those that engage parents and teachers as partners. This study highlighted the importance of engaging families and staff at preschools in order to reduce stigma and improve treatment outcomes. In providing mental health services to children, family engagement is a crucial component of treatment (Burns et al. 1999). Therefore, programs that include parents in educational programming and in interventions with the child are needed in order to address existing problems as well as prevent the development of future difficulties. A study by Gillanders et al. (2012), also underscores the importance of collaboration, and calls for engaging parents, teachers, and schools to work together to support children’s learning. Other researchers discuss the importance of the partnership between mental health professionals and teachers and emphasize the importance of collaboration between service providers in an effort to promote children’s improved mental health (Mendez et al. 2002).

Professionals in the mental health community such as social workers, marriage and family therapists, counselors, and psychologists may benefit from the results of this study, specifically those who provide services through community-based organizations. This research provides insights into how these organizations can collaborate effectively with schools and teachers, navigate the process of engaging parents, and provide therapeutic services to preschool children.