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Creating a Statewide Model of Infant and Early Childhood Mental Health Consultation: A Colorado Case Study

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Title: Creating a Statewide Model of Infant and Early Childhood Mental Health Consultation: A Colorado Case Study
Language: English
Authors: Margaret Franko (ORCID 0000-0002-6771-1814), Lindsay Shields, Elly Miles (ORCID 0000-0003-2829-8163), Lisa J. Schlueter, Allison Kallmann Wegner, Clara Prish, Kristin Klopfenstein (ORCID 0000-0002-2457-8160)
Source: Infant Mental Health Journal: Infancy and Early Childhood. 2025 46(5):615-630.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 16
Publication Date: 2025
Sponsoring Agency: Administration for Children and Families (DHHS), Office of Child Care (OCC)
Contract Number: 90TP0054
Document Type: Journal Articles
Reports - Descriptive
Education Level: Early Childhood Education
Descriptors: Mental Health, Early Childhood Education, State Programs, Program Implementation, Child Caregivers, Early Childhood Teachers, Social Emotional Learning, Consultation Programs
Geographic Terms: Colorado
DOI: 10.1002/imhj.70008
ISSN: 0163-9641
1097-0355
Abstract: The use of Infant and Early Childhood Mental Health Consultation (IECMHC) has grown dramatically over the past decade to support the skills and reflective capacity of adults who care for infants and young children birth to kindergarten entry. Research to date has shown promise for IECMHC to support children's social and emotional development. However, there is a gap in the published research that articulates how fidelity to a specific statewide IECMHC model impacts desired outcomes for adult caregivers or the infants and children they serve. This article, which articulates the process that Colorado used to develop its own IECMHC model, is the first step in filling this gap in the research. The step-by-step approach to model development can be used by other states undertaking similar efforts to create models that are geared toward a variety of settings, such as early education, home visitation, or health care. Colorado is beginning statewide implementation of the model that resulted from this process and will soon start evaluating the fidelity of that implementation. This process creates the groundwork for ultimately tying implementation of an articulated IECMHC model to outcomes for adults and the infants and children they care for.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1482981
Database: ERIC
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  Value: <anid>AN0187859956;bw601sep.25;2025Sep12.02:07;v2.2.500</anid> <title id="AN0187859956-1">Creating a statewide model of infant and early childhood mental health consultation: A Colorado case study </title> <p>The use of Infant and Early Childhood Mental Health Consultation (IECMHC) has grown dramatically over the past decade to support the skills and reflective capacity of adults who care for infants and young children birth to kindergarten entry. Research to date has shown promise for IECMHC to support children's social and emotional development. However, there is a gap in the published research that articulates how fidelity to a specific statewide IECMHC model impacts desired outcomes for adult caregivers or the infants and children they serve. This article, which articulates the process that Colorado used to develop its own IECMHC model, is the first step in filling this gap in the research. The step‐by‐step approach to model development can be used by other states undertaking similar efforts to create models that are geared toward a variety of settings, such as early education, home visitation, or health care. Colorado is beginning statewide implementation of the model that resulted from this process and will soon start evaluating the fidelity of that implementation. This process creates the groundwork for ultimately tying implementation of an articulated IECMHC model to outcomes for adults and the infants and children they care for.</p> <p>ملخص: لقد نما استخدام استشارات الصحة النفسية للرضع والطفولة المبكرة(IECMHC) بشكل كبير خلال العقد الماضي لدعم المهارات والقدرة على التفكير لدى البالغين الذين يرعون الرضع والأطفال الصغار منذ الولادة وحتى دخولهم رياض الأطفال. وقد أظهرت الأبحاث التي أجريت حتى الآن أن الاستشارة في مرحلة الطفولة المبكرة واعدة في دعم النمو الاجتماعي والعاطفي للأطفال. ومع ذلك، هناك فجوة في البحوث المنشورة التي توضح كيفية تأثير الإخلاص ودقة التنفيذ لنموذج محدد على مستوى الولاية في مجال الرعاية المتكاملة للأطفال الرضع والأطفال الصغار على النتائج المرجوة لمقدمي الرعاية البالغين أو الرضع والأطفال الذين يخدمونهم. هذه المقالة، التي توضح العملية التي استخدمتها كولورادو لتطوير نموذجها الخاص بها ، هي الخطوة الأولى في سد هذه الفجوة في البحث. يمكن استخدام النهج التدريجي لتطوير النموذج من قبل الولايات الأخرى التي تبذل جهودًا مماثلة لإنشاء نماذج موجهة نحو مجموعة متنوعة من البيئات، مثل التعليم المبكر أو الزيارات المنزلية أو الرعاية الصحية. بدأت ولاية كولورادو في تنفيذ النموذج الذي نتج عن هذه العملية على مستوى الولاية وستبدأ قريبًا في تقييم مدى دقة هذا التنفيذ. تهيئ هذه العملية الأساس لربط تنفيذ نموذج مفصل لنموذج الرعاية الصحية المتكاملة للأطفال والرضع في نهاية المطاف بالنتائج بالنسبة للبالغين والرضع والأطفال الذين يرعونهم.</p> <p>摘 要: 在过去十年中, 为支持出生至入学前的婴幼儿看护者的技能提升和反思能力, 婴幼儿心理健康咨询 (IECMHC) 的使用显著增长。现有研究表明, IECMHC对促进儿童的社交和情感发展具有积极作用。然而, 针对特定州级IECMHC模型的执行一致性如何影响成人看护者或其服务对象 (婴幼儿) 的预期结果, 目前的公开研究尚存在空白。本文阐述了科罗拉多州开发自身IECMHC模型的过程, 为填补这一研究空白迈出了第一步。这种分步骤的模型开发方法可供其他州借鉴, 以创建适用于多种场景 (如早教、家访或医疗保健) 的模型。科罗拉多州已开始在全州范围内实施基于该过程开发的模型, 并计划很快开始对其执行一致性进行评估。这一过程为最终将IECMHC模型的实施与成人及婴幼儿的发展成果联系起来奠定了基础。 Le recours à la consultation de santé mentale chez les nourrissons et les jeunes enfants (abrégé IECMHC en anglais) a connu une croissance spectaculaire au cours de la dernière décennie pour soutenir les compétences et la capacité de réflexion des adultes prenant soin de nourrissons et de jeunes enfants, de la naissance jusqu'à l'entrée à la maternelle. Les recherches menées jusqu'à présent ont montré que l'IECMHC s'est avérée être pleine de promesse pour ce qui concerne le soutien du développement social et émotionnel des enfants. Cependant, on constate un fossé entre les recherches publiées qui portent sur la façon dont la fidélité à un modèle IECMHC spécifique à l'échelle de l'État (aux Etats‐Unis) impacte les résultats attendus pour les adultes prenant soin des enfants ou les nourrissons et enfants qu'ils ou elles servent. Cet article, qui décrit le processus utilisé par l'état du Colorado pour développer son propre modèle IECMHC, est la première étape pour combler ce fossé. L'approche graduelle de développement des modèles peut être utilisée par d'autres États qui cherchent à créer des modèles axés sur divers contextes, comme l'éducation précoce, les visites à domicile ou les soins de santé. Le Colorado commence à mettre en oeuvre à l'échelle de l'État le modèle qui a résulté de ce processus et commencera bientôt à évaluer la fidélité de l'application du modèle IECMHC. Ce processus met en place les conditions préalables pour établir le lien entre l'application d'un modèle IECMHC et les résultats escomptés pour les adultes et les nourrissons et enfants qu'ils prennent en charge. In den letzten zehn Jahren hat die Beratung zur psychischen Gesundheit von Säuglingen und Kleinkindern (Infant and Early Childhood Mental Health Consultation, IECMHC) stark zugenommen, um die Fähigkeiten und das Reflexionsvermögen von Erwachsenen zu fördern, die sich um Säuglinge und Kleinkinder von der Geburt bis zum Eintritt in den Kindergarten kümmern. Die bisherige Forschung hat gezeigt, dass die IECMHC die soziale und emotionale Entwicklung von Kindern vielversprechend unterstützt. Es mangelt jedoch an veröffentlichter Forschung dazu, wie sich die Einhaltung eines bestimmten landesweiten IECMHC‐Modells auf die gewünschten Ergebnisse für erwachsene Betreuer oder die von ihnen betreuten Säuglinge und Kinder auswirkt. Dieser Artikel, der den Prozess beschreibt, den Colorado zur Entwicklung seines eigenen IECMHC‐Modells verwendet hat, ist der erste Schritt zur Schließung dieser Forschungslücke. Das schrittweise Vorgehen bei der Entwicklung des Modells kann von anderen US‐Staaten genutzt werden, die ähnliche Anstrengungen unternehmen, um Modelle für eine Vielzahl von Bereichen zu entwickeln, wie z. B. Früherziehung, Hausbesuche oder Gesundheitsfürsorge. Colorado startet derzeit mit der landesweiten Umsetzung des Modells, das aus diesem Prozess hervorgegangen ist, und wird in Kürze damit beginnen, die Einhaltung dieser Umsetzung zu bewerten. Dieser Prozess schafft die Grundlage dafür, dass die Umsetzung eines IECMHC‐Modells letztlich mit den Ergebnissen für Erwachsene und die von ihnen betreuten Säuglinge und Kinder verknüpft wird. 乳幼児期精神保健相談 (IECMHC) の利用は、出生から幼稚園入園までの乳幼児のケアにあたる大人のスキルと省察力をサポートするために、過去10年間で劇的に増加しています。これまでの研究では、IECMHCが子どもの社会性や情緒の発達を支援する上で有望であることが示されています。しかし、ある特定の州全体を対象としたIECMHCモデルに忠実に従うことが、成人養育者や彼らがケアする乳幼児に望ましい結果をもたらすかどうかを明確に示した公表された論文はさまざまである。本稿では、コロラド州が独自のIECMHCモデルを開発する際に用いたプロセスを明確に示し、この研究におけるばらつきを埋めるための第一歩である。段階的なモデル開発アプローチは、早期教育、家庭訪問、医療ケアなど、さまざまな状況に対応するモデルの作成に取り組む他の州でも活用できます。コロラド州では、このプロセスから生まれたモデルの州全体への導入を開始しており、まもなくその導入の質を評価する予定です。このプロセスは、最終的に、明確に定義されたIECMHCモデルの実施を、成人と彼らが養育する乳幼児の成果に結びつけるための基盤を構築するものです。</p> <p>Resumen: El uso de la Consulta de Salud Mental en la Infancia y la Temprana Niñez (IECMHC) ha crecido dramáticamente a lo largo de la pasada década para apoyar las habilidades y la capacidad de reflexión de adultos que les prestan cuidado a infantes y niños pequeños desde el nacimiento hasta la entrada al jardín de infancia. La investigación hasta el momento es prometedora en cuanto al apoyo que IECMHC presta al desarrollo social y emocional de los niños. Sin embargo, hay un vacío en la investigación publicada que expresa cómo la fidelidad a un modelo de IECMHC específico para todo un Estado ejerce un impacto en los deseados resultados para adultos que prestan el cuidado o los infantes y niños a quienes aquellos les sirven. Este artículo, el cual presenta el proceso que el Estado de Colorado usó para desarrollar su propio modelo de IECMHC, es el primer paso para llenar el vacío en la investigación. El acercamiento paso a paso para el desarrollo del modelo lo pueden usar otros Estados que se embarcan en esfuerzos similares para crear modelos que están orientados hacia una variedad de escenarios, tales como la temprana educación, las visitas a casa o la atención a la salud. Colorado está comenzando una implementación en todo el Estado del modelo que resultó de este proceso y pronto comenzará a evaluar la fidelidad de esa implementación. Este proceso crea el trabajo de planta para enlazar en última instancia la implementación de un articulado modelo de IECMHC con los resultados para adultos y los infantes y niños a quienes esos adultos cuidan.</p> <p>Keywords: consultation; essential elements; IECMH; IECMHC; implementation fidelity; implementation manual; infant and early childhood mental health; model development; social‐emotional; theory of change; الصحة النفسية في مرحلة الطفولة المبكرة، الاستشارة، تطوير النموذج، العناصر الأساسية، دقة التنفيذ; 幼儿心理健康; 咨询; 模型开发; 基本要素; 实施一致性; Santé mentale de la petite enfance; Consultation; Développement de modèle; éléments essentiels; Fidélité de la mise en pratique et de l'application; psychische Gesundheit von Säuglingen und Kleinkindern; Beratung; Modellentwicklung; essenzielle Elemente; Umsetzungstreue; 早期幼児期のメンタルヘルス、コンサルテーション、モデル開発、必須要素、実施の忠実性; salud mental en la temprana niñez; consulta; desarrollo de modelo; elementos esenciales; fidelidad de implementación</p> <hd id="AN0187859956-2">INTRODUCTION</hd> <p>The years spanning infancy and early childhood are critical for developing the social, emotional, and behavioral skills that will impact children's experiences in school and life (Schoon et al., [<reflink idref="bib35" id="ref1">35</reflink>]). During this time, infants and children learn to make secure attachments to adult caregivers, regulate emotions, interact with other children, and test out areas for independence (Benson & Haith, [<reflink idref="bib5" id="ref2">5</reflink>]). These skills support school readiness and later school success (Bagdi & Vacca, [<reflink idref="bib3" id="ref3">3</reflink>]). Research has demonstrated that caregivers' own social and emotional well‐being and competencies can impact children's behavior and emotional regulation (Jeon et al., [<reflink idref="bib19" id="ref4">19</reflink>]) and likelihood of preschool expulsion (Silver & Zinser, [<reflink idref="bib39" id="ref5">39</reflink>]). These understandings have led to the growth of Infant and Early Childhood Mental Health Consultation (IECMHC) as an approach to support the skills and reflective capacity of adults who care for young children.</p> <p>In IECMHC, mental health professionals work directly with early childhood professionals and other caregivers to build their capacity to support the social‐emotional development of infants and children (Hughes et al., [<reflink idref="bib17" id="ref6">17</reflink>]). Infant and Early Childhood Mental Health (IECMH) consultants form a collaborative, strength‐based relationship with their consultee as a basis for fostering self‐reflective capacity, sharing knowledge and strategies, and growing consultees' competencies (Hunter et al., [<reflink idref="bib18" id="ref7">18</reflink>]).</p> <p>Over the past two decades, experts in the field have provided an overall framework for IECMHC (Hunter et al., [<reflink idref="bib18" id="ref8">18</reflink>]; Johnston & Brinamen, [<reflink idref="bib20" id="ref9">20</reflink>]). Many states and localities across the United States have implemented some form of IECMHC (Center of Excellence, [<reflink idref="bib8" id="ref10">8</reflink>]). Colorado has funded IECMHC activities since 2006 with the initiation of IECMHC pilots in Boulder and Denver. As a strong local control state, the implementation of IECMHC in Colorado has been very localized, with practices growing organically without a consistent approach across the state. This approach has allowed consultants to respond to the unique character of each region of the state but has also led to inconsistent practices that are difficult to manage and assess as part of a statewide initiative.</p> <hd id="AN0187859956-3">Key findings include</hd> <p></p> <ulist> <item> Colorado has identified six principles of IECMHC, which include: (<reflink idref="bib1" id="ref11">1</reflink>) building adult capacity; (<reflink idref="bib2" id="ref12">2</reflink>) creating relationships with consultees; (<reflink idref="bib3" id="ref13">3</reflink>) prevention and early mental health promotion; (<reflink idref="bib4" id="ref14">4</reflink>) cultural and linguistic responsiveness; (<reflink idref="bib5" id="ref15">5</reflink>) strength‐based solutions; and (<reflink idref="bib6" id="ref16">6</reflink>) professional growth.</item> <p></p> <item> The Essential Elements of Colorado's IECMHC model define three core consultation practices: (<reflink idref="bib1" id="ref17">1</reflink>) collaborative development of data‐driven goals; (<reflink idref="bib2" id="ref18">2</reflink>) provision of relevant coaching, training, and modeling; and (<reflink idref="bib3" id="ref19">3</reflink>) use of the consultative stance.</item> <p></p> <item> The ten elements of the consultative stance can be grouped into three categories: (<reflink idref="bib1" id="ref20">1</reflink>) elevating the consultee experience/expertise; (<reflink idref="bib2" id="ref21">2</reflink>) understanding and integrating influencing factors; and (<reflink idref="bib3" id="ref22">3</reflink>) modeling and communicating support.</item> </ulist> <hd id="AN0187859956-4">Relevance and Key Findings</hd> <p>This article describes the development and content of Colorado's IECMHC model and how it will be used as the basis for implementation fidelity and outcomes evaluation. This process and the model itself have potential application in other states and localities and for use in practice settings, such as home visiting, health care, child welfare, and early intervention.</p> <p>In response, the IECMHC program managed at the Colorado Department of Early Childhood (CDEC) has paired with researchers at the University of Denver to clearly articulate the state's IECMHC implementation model, first in early care and education settings, apply that model in practice, and evaluate the results. This 5‐year effort began in 2021 with the development of a set of Essential Elements and a theory of change that would form the backbone of Colorado's IECMHC model. This article describes the development and content of Colorado's IECMHC model and how it will be used as the basis for implementation fidelity and outcomes evaluation. This process and the model itself have potential application in other states and localities and for use in practice settings, such as home visiting, health care, child welfare, and early intervention (Miles et al., [<reflink idref="bib25" id="ref23">25</reflink>]). By clearly articulating a specific model of IECMHC, subsequent research based on that model can also be replicated and validated. Additionally, most published research relies on a broad definition of IECMHC with little to no specification of models or the processes that led to their development. This article adds to the research base by describing the process Colorado has undertaken to define a specific IECMHC model to be used statewide within early care and education settings.</p> <hd id="AN0187859956-5">LITERATURE REVIEW</hd> <p>IECMHC is an evolving field that relies on individual relationship‐building as a core practice. In part because of this value of individualized services, many varied approaches to IECMHC exist across a range of types of programs and care settings. The research reviewed throughout this section reflect this varied nature of IECMHC delivery and so makes drawing generalizable conclusions across the field unreliable. Additionally, the variability of IECMHC implementation has largely been overlooked within existing literature. However, research presented here offers an important starting point to consider where the field, and Colorado in particular, might go next as researchers and practitioners continue to define and solidify effective approaches to IECMHC.</p> <hd id="AN0187859956-6">Social‐emotional development</hd> <p>The years spanning infancy and early childhood are critical for the development of social‐emotional skills. Nearly 20 years ago, the National Education Goals Panel identified social‐emotional skills, such as self‐regulation and the ability to express emotions, as one of five key dimensions of school readiness (Kagan et al., [<reflink idref="bib21" id="ref24">21</reflink>]). Since then, researchers have reaffirmed its important role for children in navigating school and life (Bagdi & Vacca, [<reflink idref="bib3" id="ref25">3</reflink>]; National Research Council and Institute of Medicine, [<reflink idref="bib29" id="ref26">29</reflink>]).</p> <p>Social‐emotional skills develop in a range of contexts, including within families and in early care and early education settings. The ability of caregivers to build the social‐emotional competencies of infants and young children can depend on the caregiver's own social‐emotional skills and background as well as their capacity to respond to developmentally appropriate but sometimes challenging behaviors from the children in their care (Hughes et al., [<reflink idref="bib17" id="ref27">17</reflink>]). For instance, caregivers' own exposure to adverse childhood experiences has been shown to impact their emotional availability to support young children's social‐emotional development (Ziv et al., [<reflink idref="bib47" id="ref28">47</reflink>]). Caregiver stress can also impact how they perceive the behavior and emotional capacities of infants and young children, with more stressed caregivers perceiving children as more angry, aggressive, anxious, and withdrawn than similar caregivers under less stress (Jeon et al., [<reflink idref="bib19" id="ref29">19</reflink>]). In some cases, caregivers' emotional states can lead to infants' and young children's increased expulsions from child care and preschool. In one study, researchers found that caregivers experiencing depression were more likely to request that children be expelled from care, but that support from IECMH consultants helped reduce such expulsions (Silver & Zinsser, [<reflink idref="bib39" id="ref30">39</reflink>]).</p> <hd id="AN0187859956-7">Infant and early childhood mental health consultation</hd> <p>Because of the important role that caregivers play in building young children's social‐emotional skills, IECMHC has emerged as an approach to building the capacity of early childhood professionals to support the social‐emotional development of infants and children. Experts in the field have identified core principles of practice (Hunter et al., [<reflink idref="bib18" id="ref31">18</reflink>]), approaches to consultation (Johnston & Brinamen, [<reflink idref="bib20" id="ref32">20</reflink>]), and professional competencies (Center of Excellence for Infant & Early Childhood Mental Health Consultation, [<reflink idref="bib7" id="ref33">7</reflink>].; Korfmacher, [<reflink idref="bib24" id="ref34">24</reflink>]; Office of Head Start, The National Center on Health, [<reflink idref="bib31" id="ref35">31</reflink>].) that IECMH consultants should possess to effectively support caregivers. Common elements include the collaborative nature of IECMHC, the importance of culturally responsive, developmentally grounded, and relationship‐based practices, and integration of services with other community supports when possible. Consultation typically takes place in settings that are natural to the child and family, such as the home or child care. In the latter, consultation can be delivered at the programmatic, classroom, or child and family level (Hunter et al., [<reflink idref="bib18" id="ref36">18</reflink>]).</p> <hd id="AN0187859956-8">Implications of IECMHC for children and caregivers</hd> <p>The evidence base for IECMHC[<reflink idref="bib1" id="ref37">1</reflink>] demonstrates that it is associated with positive outcomes for infants and young children as well as caregivers. An initial systematic review found that IECMHC was linked to a reduction in children's externalizing behaviors and improvements in prosocial behaviors (Perry et al., [<reflink idref="bib33" id="ref38">33</reflink>]). A subsequent, updated review confirmed these relationships, as well as associations with caregiver self‐efficacy and caregiver‐child interactions, while further exploring the factors of IECMHC associated with specific outcomes, how those factors operate, for whom, and in what contexts (Silver et al., [<reflink idref="bib38" id="ref39">38</reflink>]). Silver et al ([<reflink idref="bib40" id="ref40">40</reflink>]) identified dosage as positively associated with teacher and child outcomes and found evidence that the quality of caregivers' experiences with IECMHC significantly impacts outcomes for the teacher‐child relationship, classroom climate, and children's attachment. They also found that the effectiveness of IECMHC was affected by teacher mental health (e.g., depression) and age, with younger teachers more impacted by the intervention than older teachers. Children with lower baseline scores for protective factors and behavior also saw greater benefit from IECMHC services. Individual studies have found positive effects in both center‐ and home‐based early care and education settings in rural environments (Vuyk et al., [<reflink idref="bib44" id="ref41">44</reflink>]) and with multi‐ethnic populations in urban settings (Natale et al., [<reflink idref="bib28" id="ref42">28</reflink>]). Others have identified associations between IECMHC and reductions in suspension and expulsion (Silver & Zinsser, [<reflink idref="bib39" id="ref43">39</reflink>]; Miles et al., [<reflink idref="bib27" id="ref44">27</reflink>]), improvements in caregiver‐child interactions (Amini Virmani et al., [<reflink idref="bib2" id="ref45">2</reflink>]; (Conners‐Burrow et al., [<reflink idref="bib10" id="ref46">10</reflink>]), and child and peer behaviors (Gilliam et al., [<reflink idref="bib15" id="ref47">15</reflink>]; Reyes & Gilliam, [<reflink idref="bib34" id="ref48">34</reflink>]).</p> <p>There is also growing evidence that IECMHC has the potential to mitigate racial disparities in suspension and expulsion of infants and young children from early care and education settings. One study pointed to IECMHC as an effective strategy for reducing implicit biases that can impact disciplinary decisions (Davis et al., [<reflink idref="bib12" id="ref49">12</reflink>]), while another found a significant decrease in caregiver‐child conflict scores for Black children after IECMHC services with caregivers (Shivers et al., [<reflink idref="bib38" id="ref50">38</reflink>]). While not explicitly examined in the literature, through its emphasis on equity and developing adults' understanding of children's mental health needs, IECMHC may also be able to address known disproportionalities in exclusionary discipline for children with disabilities (Miles et al., [<reflink idref="bib27" id="ref51">27</reflink>]; Novoa & Malik, [<reflink idref="bib30" id="ref52">30</reflink>]; Zeng et al., [<reflink idref="bib45" id="ref53">45</reflink>]).</p> <hd id="AN0187859956-9">Fidelity of implementation</hd> <p>As more states begin to adopt IECMHC models to support early care and education programs and caregivers, a handful of studies have explored what is needed to create fidelity of implementation across a statewide model of IECMHC. According to one author, "Different models for this process continue to evolve, which can lead to variability in its implementation. In addition, its focus is wide‐ranging, from addressing children's challenging behavior to assessing the quality of children's social and emotional environments" (Hughes et al., [<reflink idref="bib17" id="ref54">17</reflink>]). Early research in this area has led to the identification of core implementation features that include a solid program infrastructure, highly qualified mental health consultants, and high‐quality services (Kaufmann et al., [<reflink idref="bib22" id="ref55">22</reflink>]). Solid program infrastructure was defined as a clear model design, well‐developed hiring and training practices, regular supervision and support for IECMH consultants, articulation of the model to the field, and an evaluation strategy to support ongoing data collection, monitoring, and evaluation.</p> <p>More recent research has sought to better define the activities of IECMHC. Using a Delphi process, researchers identified five essential elements of consultation, along with related activities. Elements of IECMHC included (<reflink idref="bib1" id="ref56">1</reflink>) structuring the process for consultation (e.g., collaboratively defining vision for consultation, supporting the consultees as they implement); (<reflink idref="bib2" id="ref57">2</reflink>) building and nurturing equitable relationships with consultees; (<reflink idref="bib3" id="ref58">3</reflink>) fostering consultee capacity to think and act in new ways; (<reflink idref="bib4" id="ref59">4</reflink>) empowering consultees to enhance equity in their roles; and (<reflink idref="bib5" id="ref60">5</reflink>) attending to consultant skills, self‐care, and self‐awareness (Davis Schoch et al., [<reflink idref="bib13" id="ref61">13</reflink>]). While these elements move the field toward a shared understanding of the basics of IECMHC, this framework has not yet been consistently adopted or used to monitor implementation fidelity.</p> <p>To date, there is limited published research exploring the implementation and evaluation of a statewide IECMHC model. One study details Louisiana's implementation of a hybrid child‐ and program‐focused IECMHC model statewide and links that with an increase in caregiver self‐efficacy and reported increases in competency with social‐emotional learning (Heller et al., [<reflink idref="bib16" id="ref62">16</reflink>]). Another describes Virginia's experience piloting an IECMHC model across 30 early care and education programs in one large region of the state and identifies tensions and issues that can impact scale‐up (Partee et al., [<reflink idref="bib32" id="ref63">32</reflink>]). In Illinois, a statewide partnership conducted a 3‐year pilot study of a comprehensive IECMHC model focused on teachers' reflective capacity, burnout, and perceptions of children's behavior as part of an effort to expand IECMHC services across systems and settings (Spielberger et al., [<reflink idref="bib41" id="ref64">41</reflink>]). Two randomized control trials (RCT) in Connecticut (Gilliam et al. [<reflink idref="bib15" id="ref65">15</reflink>]) and Ohio (Reyes & Gilliam, [<reflink idref="bib34" id="ref66">34</reflink>]) explored impacts of those statewide programs on child (Connecticut and Ohio) and teacher (Ohio) outcomes. States that are building IECMHC models, like Colorado, have a strong interest in designing and implementing models that will have the best outcomes for infants, children, and their caregivers. However, the current literature in the field is limited. This article seeks to help fill this gap.</p> <hd id="AN0187859956-10">BUILDING CONSENSUS TOWARDS A COLORADO IECMHC MODEL</hd> <p>In Colorado, the state legislature passed HB20‐1053 during the 2020 legislative session. The bill requires the development of a "defined model of consultation that is rooted in diversity, equity, and inclusion" and "that includes qualifications and competencies for mental health consultants, job expectations, expected outcomes, and guidance on ratios" (Colorado General Assembly, [<reflink idref="bib9" id="ref67">9</reflink>]). Colorado's Department of Early Childhood (previously the Office of Early Childhood) began the process of model development with a national scan of state IECMHC models, followed by development of dosage expectations and interviews with the IECMHC workforce to understand current practices in the field. Subsequent steps included the development of a theory of change and an articulation of "Essential Elements" as foundational for Colorado's model of IECMHC. Based on this work, the research team developed an implementation manual for use in the field. Throughout this process, the state and researchers sought ongoing guidance from an advisory body of IECMH consultants and national experts (Figure 1).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/BW6/01sep25/imhj70008-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="imhj70008-fig-0001.jpg" title="1 Model development process." /> </p> <p></p> <hd id="AN0187859956-12">National scan of state infant and early childhood mental health consultation models</hd> <p>The initial step in model development began with a national scan of other states' IECMHC models[<reflink idref="bib2" id="ref68">2</reflink>] (Miles & Schlueter, [<reflink idref="bib26" id="ref69">26</reflink>]). The national scan used website‐searches, interviews, and surveys to gather information from state IECMHC leads to learn about the status of program infrastructure for IECMHC in each state. Participants were invited to participate in either a survey or interview. Both surveys and interviews included questions about each state's model, the evidence base that informed the model, barriers to implementation that the state experienced, and how outcomes were evaluated.</p> <p>The scan identified thirteen states that had an IECMHC model developed and evaluated as of February 2020, though not all of these models were available statewide. State IECMHC leads self‐identified whether they had a model developed and evaluated. Leads additionally specified if they provided child, classroom, or programmatic services and whether or not they evaluated outcomes. The research team included any evaluation with pre and post measurement of child‐, classroom‐, or program‐focused outcomes, but did not set further inclusion criteria. Eight more states had programs that were developed but had not been evaluated or their evaluation status was in progress or unknown, while ten states had programs in development at that time. Twenty states had no IECMHC program model identified at the time of the scan or insufficient contact was made with state leads to understand the development and status of their model (see Table 1).</p> <p>1 TABLE 2019 State‐reported Status of IECMHC Models.</p> <p> <ephtml> <table><thead><tr><th>Model developed and evaluated</th><th>Model developed/no evaluation completed</th><th>Model in development</th><th>No model/Insufficient information to assess model status</th></tr></thead><tbody><tr><td><list list-type="Bullet"><list-item><p>Arizona</p></list-item><list-item><p>Arkansas</p></list-item><list-item><p>California (San Francisco) <ext-link /><sup>*</sup></p></list-item><list-item><p>Connecticut</p></list-item><list-item><p>District of Columbia</p></list-item><list-item><p>Louisiana</p></list-item><list-item><p>Maryland</p></list-item><list-item><p>Michigan</p></list-item><list-item><p>Nebraska (Omaha) <ext-link /><sup>*</sup></p></list-item><list-item><p>New York (New York City) <ext-link /><sup>*</sup></p></list-item><list-item><p>Ohio</p></list-item><list-item><p>Oregon (Portland) <ext-link /><sup>*</sup></p></list-item><list-item><p>Pennsylvania</p></list-item></list></td><td><list list-type="Bullet"><list-item><p>Alabama</p></list-item><list-item><p>Illinois</p></list-item><list-item><p>Kentucky</p></list-item><list-item><p>Massachusetts</p></list-item><list-item><p>Minnesota</p></list-item><list-item><p>New Hampshire</p></list-item><list-item><p>Rhode Island</p></list-item><list-item><p>Virginia</p></list-item></list></td><td><list list-type="Bullet"><list-item><p>Colorado</p></list-item><list-item><p>Florida</p></list-item><list-item><p>Maine</p></list-item><list-item><p>Missouri</p></list-item><list-item><p>Montana</p></list-item><list-item><p>South Carolina</p></list-item><list-item><p>Texas</p></list-item><list-item><p>Utah</p></list-item><list-item><p>Washington</p></list-item><list-item><p>Wisconsin</p></list-item></list></td><td><list list-type="Bullet"><list-item><p>Alaska</p></list-item><list-item><p>Delaware</p></list-item><list-item><p>Georgia</p></list-item><list-item><p>Hawaii</p></list-item><list-item><p>Idaho</p></list-item><list-item><p>Indiana</p></list-item><list-item><p>Iowa</p></list-item><list-item><p>Kansas</p></list-item><list-item><p>Mississippi</p></list-item><list-item><p>Nevada</p></list-item><list-item><p>New Jersey</p></list-item><list-item><p>New Mexico</p></list-item><list-item><p>North Carolina</p></list-item><list-item><p>North Dakota</p></list-item><list-item><p>Oklahoma</p></list-item><list-item><p>South Dakota</p></list-item><list-item><p>Tennessee</p></list-item><list-item><p>Vermont</p></list-item><list-item><p>West Virginia</p></list-item><list-item><p>Wyoming</p></list-item></list></td></tr></tbody></table> </ephtml> </p> <p>1 <sups>*</sups>IECMHC models in these states were in place in the specified city only.</p> <p>The Center of Excellence for Infant and Early Childhood Mental Health Consultation (Center of Excellence) has identified three types of IECMHC services: child, classroom, and programmatic (Hunter et al., [<reflink idref="bib18" id="ref70">18</reflink>]). Of the 31 states with an existing model or one in development, the national scan found that all but two states included all three service types in their models. In 2019 (or at the time of data collection), only Nebraska (Omaha) and Pennsylvania reported that their model did not include program‐focused services.</p> <p>The 21 states that had a developed model at the time of the scan identified one or more tools or trainings that they incorporate into their IECMHC model. The most common included the Pyramid Model, reflective supervision/consultation (RS/C), Facilitating Attuned Interactions (FAN), Conscious Discipline, and Incredible Years (Table 2). Other tools or trainings were used by just one or two states and included Foundations in Infant Mental Health, the Infant Mental Health Endorsement, Devereux Toolbox, Teacher‐Child Interaction Training, motivational interviewing, and Circle of Security. Seven survey respondents additionally described reflective supervision as a service delivery framework.</p> <p>2 TABLE Tools and trainings incorporated into IECMHC models.</p> <p> <ephtml> <table><thead><tr><th>Evidence‐based tool or training</th><th>Number of states incorporating in model (<italic>n</italic> = 21)</th></tr></thead><tbody><tr><td>Pyramid model</td><td>13</td></tr><tr><td>Reflective supervision/consultation</td><td>9</td></tr><tr><td>Facilitating attuned Interactions (FAN)</td><td>7</td></tr><tr><td>Conscious discipline</td><td>5</td></tr><tr><td>Incredible years</td><td>4</td></tr></tbody></table> </ephtml> </p> <p>Another key aspect of IECMHC models that Colorado researchers were interested in was dosage or the frequency, intensity, and duration of IECMHC services. Among the 21 states with developed models, respondents reported that IECMH consultants typically conduct 1–4 h visits weekly across all three types of consultation services. Services typically last between 1 and 6 months, but this can vary, particularly for child‐focused services. Table 3 provides additional detail by service type.</p> <p>3 TABLE Reported frequency, intensity, and duration within state IECMHC models.</p> <p> <ephtml> <table><thead><tr><th /><th>Frequency</th><th>Intensity</th><th>Duration</th></tr></thead><tbody><tr><td>Child‐focused services (n = 21)</td></tr><tr><td>Most common</td><td>1–2 times/week</td><td>1–4 h</td><td>Varied/no limit</td></tr><tr><td>Range</td><td>2x/week‐every 4 months</td><td>1–8 h</td><td>2–27 months</td></tr><tr><td>Classroom‐focused services (n = 20)</td></tr><tr><td>Most common</td><td>1x/week</td><td>1–2 h</td><td>1–3 months</td></tr><tr><td>Range</td><td>2x/month‐1x/week</td><td>2–12 h/month</td><td>1–27 months</td></tr><tr><td>Program‐focused services (n = 4)</td></tr><tr><td>Most common</td><td>1–2 times/week</td><td>1–3 h</td><td>1–6 months</td></tr><tr><td>Range</td><td>1x/week‐variable amounts</td><td>1 h‐variable amounts</td><td>1–12 months</td></tr></tbody></table> </ephtml> </p> <p>The survey and interview included questions on how evaluation results may have informed selected model dosage. One state (Ohio) discussed that 3 years of evaluation data had informed their selected dosage duration, as clinical effectiveness and statistically significant improvements emerged at standard points in the context of high‐fidelity model implementation. However, they noted that their commitment to equity resulted in adjusting duration at the IECMHC implementation site/provider level until satisfactory outcomes were obtained due to a strong outcomes‐focused, as opposed to process‐focused, approach in their model.</p> <p>In summary, the national scan produced a point‐in‐time snapshot of IECMHC services across a large number and variety of states. In the interim, states have continued to develop their own IECMHC services and models, particularly following the COVID pandemic and the rapidly expanding needs and innovative approaches that resulted. The data presented here serves as a baseline as reported at the time of inquiry in 2019 and does not necessarily reflect current service levels or models.</p> <hd id="AN0187859956-13">Development of statewide dosage expectations</hd> <p>As part of its IECMHC model development process, Colorado researched and articulated the appropriate number of service hours that consultants should provide for each service type. The state recruited a core team of twelve IECMHC stakeholders that included practitioners and academics from across Colorado to develop the dosage expectations. The team represented more than fourteen rural and urban counties and had an average of 10 years of experience with IECMHC (Bellomo et al., [<reflink idref="bib4" id="ref71">4</reflink>]). Members included experts from the health, mental health, and early childhood fields. Together, this core team participated in 12 h of workshops, assessed dosage data from Colorado's state data system, reviewed dosage models from other states, examined relevant peer reviewed research, and solicited feedback from stakeholders on possible dosage models for Colorado. Resulting dosage recommendations are presented in Table 4. Recommendations are offered as a range, rather than fixed numbers, to account for contextual variations in cases.</p> <p>4 TABLE Colorado's recommended dosage expectations.</p> <p> <ephtml> <table><thead><tr><th /><th>Frequency</th><th>Intensity</th><th>Duration</th></tr></thead><tbody><tr><td>Child‐focused services</td></tr><tr><td>Minimum</td><td>1x/month</td><td>6 h/case</td><td>2 months</td></tr><tr><td>Maximum</td><td>3x/month</td><td>60 h/case</td><td>6 months</td></tr><tr><td>Classroom‐focused services</td></tr><tr><td>Minimum</td><td>2x/month</td><td>12 h/case</td><td>3 months</td></tr><tr><td>Maximum</td><td>3x/week</td><td>120 h/case</td><td>9½ months(academic year)</td></tr><tr><td>Embeddeda</td><td>N/A</td><td>8 h/week</td><td>N/A</td></tr><tr><td>Program‐focused services</td></tr><tr><td>Minimum</td><td>1x/month</td><td>2 h/month</td><td>Brief consult</td></tr><tr><td>Maximum</td><td>5x/week</td><td>12 h/month</td><td>12 months(option to renew)</td></tr><tr><td>Embedded</td><td>N/A</td><td>24 h/week</td><td>N/A</td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Source</emph>: <emph>Bellomo et al.</emph>, [<reflink idref="bib4" id="ref72">4</reflink>]; <sups>a</sups> "Embedded" refers to situations in which a consultant provides IECMH consulting to a limited or restricted list of programs with which they have specific service agreements.</p> <p>To ensure that services are not prematurely ended for clients with additional needs that may not be met by standard service delivery limits, the dosage team identified ten conditions under which additional dosage beyond recommendations may be warranted (Bellomo et al., [<reflink idref="bib4" id="ref73">4</reflink>]). These included instances where a child is at risk of suspension or expulsion, adults in the infant or child's life are experiencing mental health or substance use issues, or where there are challenges to making referrals, among others. In these cases, IECMH consultants may provide services outside the identified frequency, intensity, and dosage expectations.</p> <hd id="AN0187859956-14">Interviews with the infant and early childhood mental health consultation workforce</hd> <p>After conducting its national scan and establishing statewide dosage expectations, the IECMHC program managed at the Colorado Department of Early Childhood (CDEC) contracted with researchers at the Colorado Evaluation and Action Lab (Colorado Lab) at the University of Denver in March 2021 for ongoing development of the IECMHC model and evaluation of the model's impact and effectiveness (expected by 2026). At that time, the Colorado Lab sub‐contracted with the Urban Institute to conduct interviews with IECMH consultants and supervisors across the state. After 15 years of IECMHC practice in Colorado, the primary goal of the interviews was to learn more about the work IECMH consultants were doing in the field and understand how IECMHC was operating in the state, with the ultimate intention of incorporating this information into model development. During the spring and summer of 2021, the researchers interviewed 59 IECMH consultants and supervisors who worked across all 18 IECMHC implementation sites representing a broad geographic range (Urban Institute, [<reflink idref="bib43" id="ref74">43</reflink>]).</p> <p>The interview protocol focused on three main topics: (<reflink idref="bib1" id="ref75">1</reflink>) what components of consultants' practice might be considered core or "Essential Elements" of IECMHC; (<reflink idref="bib2" id="ref76">2</reflink>) what a day in the life of an IECMH consultant looks like at each distinct service level (program‐, classroom‐, and child‐focused consultation); and (<reflink idref="bib3" id="ref77">3</reflink>) needed supports and experienced challenges with service delivery. The evaluation team analyzed the interview data using an a priori coding scheme that surfaced several findings relevant to model development (Urban Institute, [<reflink idref="bib43" id="ref78">43</reflink>]):</p> <p> <bold>Essential elements of IECMHC</bold>. According to consultants and supervisors, the following are at the heart of IECMHC:</p> <p></p> <ulist> <item> A focus on supporting the skills and capacity of adults who care for infants and young children.</item> <p></p> <item> Relationship‐building between consultants and clients.</item> <p></p> <item> Providing positive feedback and emphasizing client's expertise.</item> <p></p> <item> Building the reflective capacity of clients.</item> <p></p> <item> Providing guidance and modeling of effective practices and approaches.</item> </ulist> <p> <bold>Levels of service</bold>. Consultants reported they found it difficult to distinguish practices across the child, classroom, and program levels. They spend time delivering services at each level and use similar strategies and skills in each instance. This is especially true across child‐ and classroom‐focused services. They did note, however, that child‐focused cases can be more time‐consuming and urgent than at other levels. Additionally, child and classroom cases generally involve working with or near infants or children in some capacity, while program‐focused cases tend to have limited interactions with children.</p> <p> <bold>Service duration</bold>. Consultants reported struggling to identify clear end points for services, particularly when consultants are embedded within a site. While being embedded gives consultants a sense of consistency that allows them to continually check in and monitor client progress, their cases don't have natural end points the way on‐call cases do. Staff turnover or newly identified goals with existing consultees can lead to extended service duration. Overall, consultants reported the greatest confidence with knowing when to close a child‐focused case. They generally rely on subjective criteria or consultee‐initiated terminations to decide when to close cases, such as observing a client's increased confidence with classroom management or noticing improvements in clients' feelings of competence.</p> <hd id="AN0187859956-15">Colorado's essential elements of infant and early childhood mental health consultation</hd> <p>The Essential Elements of Colorado's IECMHC program are the result of previously described efforts to identify the core functions and associated activities that are necessary for Colorado's IECMHC program to achieve its desired outcomes. They are central to the development of an IECMHC model for the state and flow from the national scan, assessment of dosage expectations, and interviews with IECMH consultants. The Essential Elements are categorized into three buckets: Principles, Context and Structure, and Consultation Practices. The Principles (Table 5) describe the key assumptions in which IECMHC is grounded; Context and Structure (Table 6) broadly outline what implementation looks like; and Consultation Practices (Table 7) more specifically cover the activities consultants do in their day‐to‐day work.</p> <p>5 TABLE Essential elements: Principles.</p> <p> <ephtml> <table><tbody><tr><td>IECMHC is focused on building the capacity of adults. It is not about "fixing kids."</td><td /></tr><tr><td>IECMHC is based on strong, positive relationships with adults providing care for young children.</td><td /></tr><tr><td>IECMHC is focused on prevention and early mental health promotion.</td><td /></tr><tr><td>IECMHC aims to be culturally and linguistically responsive and works to understand how culture, language, and community impact all aspects of caregiving and child‐rearing.</td><td /></tr><tr><td>IECMHC is strengths‐based and grounded in equity. It builds upon the abilities and positive qualities of all children, families, and early childhood professionals.</td><td /></tr><tr><td>IECMH consultants are supported through professional development and reflective supervision to deepen their practice.</td><td /></tr></tbody></table> </ephtml> </p> <p>6 TABLE Context and structure.</p> <p> <ephtml> <table><tbody><tr><td>Consultants work with adults providing care for children age birth to 6, including the prenatal period.</td><td /></tr><tr><td>Consultation occurs in settings where children learn and grow.</td><td /></tr><tr><td>Consultants may be embedded within a program/organization or set of organizations.</td><td /></tr><tr><td>Consultants follow program guidance on frequency, intensity, and duration of service delivery.</td><td /></tr></tbody></table> </ephtml> </p> <p>7 TABLE Colorado consultation activities.</p> <p> <ephtml> <table><thead><tr><th>Activities</th><th>Description</th></tr></thead><tbody><tr><td>Coaching</td><td>Supporting and guiding consultees in implementing action steps toward their goals</td></tr><tr><td>Training</td><td>Providing individual or group training on a topic related to social emotional development or mental health</td></tr><tr><td>Modeling</td><td>Demonstrating or role‐playing a strategy or practice that a consultee might use, for the purpose of having the consultee incorporate it into their own practice</td></tr><tr><td>Reflection</td><td>Modeling wondering and providing space to debrief the consultee's actions, emotions, influences, and perspectives</td></tr><tr><td>Education</td><td>Providing written or verbal information about a goal‐relevant topic</td></tr></tbody></table> </ephtml> </p> <p>3 <emph>Source</emph>: <emph>Early Childhood Mental Health Consultation (ECMHC) Colorado Implementation Manual</emph>.[<reflink idref="bib3" id="ref79">3</reflink>].</p> <p> <bold>Principles</bold>. The IECMHC principles serve two purposes: to define what IECMHC is and is not and to describe expected approaches to the work. Colorado has identified six principles of IECMHC, which include: (<reflink idref="bib1" id="ref80">1</reflink>) building adult capacity; (<reflink idref="bib2" id="ref81">2</reflink>) creating relationships with consultees; (<reflink idref="bib3" id="ref82">3</reflink>) prevention and early mental health promotion; (<reflink idref="bib4" id="ref83">4</reflink>) cultural and linguistic responsiveness; (<reflink idref="bib5" id="ref84">5</reflink>) strength‐based solutions; and (<reflink idref="bib6" id="ref85">6</reflink>) professional growth.</p> <p> <bold>Building adult capacity</bold>. IECMHC is focused on building the capacity of adults who care for infants and young children to support their healthy social and emotional development. This principle is based on evidence that the child's environment and adult‐child interactions influence children's social, emotional, and behavioral expression (Jeon et al., [<reflink idref="bib19" id="ref86">19</reflink>]; Conners Edge et al., [<reflink idref="bib11" id="ref87">11</reflink>]). The intent of this principle is to focus services on giving early educators, program directors, families, and others providing care to infants and young children with the skills and strategies they need to address their own wellbeing, promote a warm and responsive care environment, decrease behaviors adults find challenging, reduce suspensions and expulsions, and encourage positive social‐emotional development.</p> <p> <bold>Creating relationships with consultees</bold>. This principle encourages IECMH consultants to develop strong interpersonal relationships with consultees. Evidence suggests that there needs to be a high level of trust between IECMH consultants and consultees for self‐reflection and practical changes to occur (Kniegge‐Tucker et al., [<reflink idref="bib23" id="ref88">23</reflink>]; Shea et al., [<reflink idref="bib37" id="ref89">37</reflink>]). By building an authentic, trusting relationship with consultees, IECMH consultants provide the space for genuine and effective collaboration. Consultants foster these relationships using strategies such as holding hope, avoiding the position of expert, building upon the strengths of early childhood professionals and families and by working to understand how individual experiences impact caregiving and expectations of child‐rearing.</p> <p> <bold>Prevention and early mental health promotion</bold>. Key goals for IECMHC in Colorado are to increase the confidence and ability of caregivers to support healthy social‐emotional development for all of the children they care for, to find and address mental health and developmental issues early, and to reduce or eliminate suspensions and expulsions. This principle reflects these goals by emphasizing prevention and early mental health promotion. IECMH consultants work with early educators, program directors, families, and others providing care to infants and young children to provide them with the needed skills and capacity to proactively promote children's social, emotional, and behavioral well‐being.</p> <p> <bold>Cultural and linguistic responsiveness</bold>. Child development occurs within the context of a family's culture. In the IECMHC context, the consultant needs awareness of how their own cultural and linguistic identity may impact how they support the adults caring for children. Similarly, adult caregivers are also influenced by their own cultural and linguistic identities and those of the children and families with whom they work. This principle emphasizes the importance of understanding and honoring the culture and language of caregivers, families, and children within the context of IECMHC principles and practices.</p> <p> <bold>Strengths‐based solutions</bold>. This principle reflects a core belief within IECMHC that all individuals, including both children and adults, have unique experiences and expertise to bring to their interactions and environments. Research also supports the idea that drawing on people's existing strengths to address challenges results in more openness to identifying and using new practices (Shea et al., [<reflink idref="bib37" id="ref90">37</reflink>]; Shahmoon‐Shanok & Geller, [<reflink idref="bib36" id="ref91">36</reflink>]). In the context of IECMHC, consultants are encouraged to identify consultees' strengths and leverage those to find and implement solutions that benefit both the children and the adults caring for them.</p> <p> <bold>Professional growth</bold>. The last principle acknowledges the significant skill, insight, and compassion that consultants must bring to their work by emphasizing their need for ongoing professional development and time to reflect on their work with consultees. There are increasing resources for IECMH consultants to engage in professional development, including online tutorials from national Head Start and the Center of Excellence to state‐specific offerings, such as those offered on Colorado's Professional Development and Information System (PDIS). Reflective supervision supports professional growth in a more ongoing, personal, and interactive way by creating a reliable space for consultants to reflect on their own work and experiences within a collaborative relationship with a qualified reflective supervisor.</p> <p> <bold>Context and structure</bold>. The context and structure section of the Essential Elements provides additional details about: (<reflink idref="bib1" id="ref92">1</reflink>) age ranges served; (<reflink idref="bib2" id="ref93">2</reflink>) service settings; (<reflink idref="bib3" id="ref94">3</reflink>) consultant relationships to settings; and (<reflink idref="bib4" id="ref95">4</reflink>) dosage.</p> <p> <bold>Age ranges served</bold>. Colorado's IECMHC program works directly with caregivers of children birth to age 6, as well as adults in the prenatal period. Early childhood is typically defined as birth‐age 8 (American Academy of Pediatrics, [<reflink idref="bib1" id="ref96">1</reflink>]), but based on definitions articulated by national early childhood organizations (Zero to Three, [<reflink idref="bib46" id="ref97">46</reflink>]) and given that the settings for IECMHC are generally those where children are in the years before K‐12 education, Colorado's program focuses on prenatal adults and those serving children up to age 6.</p> <p> <bold>Service settings</bold>. Consultation can and does occur in a wide variety of settings where infants and young children learn, grow, and develop. Although incoming service requests typically come from child care and preschool environments (and the Colorado model was developed with these settings in mind), consultants can serve other program settings. These can include family homes, child welfare offices, health clinics, and other places where adults provide care and services to infants, toddlers, and preschool‐age children. In these instances, consultees might be parents, home visitors, child welfare case workers, or health care workers.</p> <p> <bold>Relationship to setting</bold>. Consultants who regularly work within the same child care or preschool setting(s) are described as being "embedded" within a program. These consultants have a deep relationship with at least one center. This terminology applies to a consultant who serves several classrooms within one or more child care centers exclusively, works within one or more child care centers exclusively, or has a deep, ongoing relationship with one or more centers while also maintaining a handful of outside client cases. Other consultants who are not embedded serve a variety of different centers or settings based on where the need arises.</p> <p> <bold>Dosage</bold>. Within implementation science, dosage refers to the frequency, intensity, and duration of the service or activity that is expected to bring about the desired results. Within the context of IECMHC, dosage refers to how often the consultant will meet with the consultee to address a clear set of mutually defined goals, what the length of those visits will be, and how many visits the consultant and consultee have together. The intention of IECMHC dosage guidelines (the development of which is described earlier in this article) is to ensure equitable access to IECMHC services and consistent, high‐quality service provision across the state.</p> <p> <bold>Consultation practices</bold>. The Essential Elements define three core consultation practices: (<reflink idref="bib1" id="ref98">1</reflink>) collaborative development of data‐driven goals; (<reflink idref="bib2" id="ref99">2</reflink>) provision of relevant coaching, training, and modeling; and (<reflink idref="bib3" id="ref100">3</reflink>) use of the consultative stance.</p> <p> <bold>Collaborative development of data‐driven goals</bold>. Consultants and consultees work together to define success for the consultation period and prioritize action steps at the beginning of consultation services. They use data from assessments and informal or formal observations along with the consultees' own priorities to identify goals, action steps, and intended outcomes. These goals and related action steps define the service plan that the consultant and consultee work on over subsequent visits together. Because IECMHC is dynamic and adaptable, consultants and consultees revisit goals over the course of their work together to assess progress and make any needed changes to the goal itself or the action steps to achieve outcomes that are closely related to the Essential Elements and theory of change.</p> <p> <bold>Coaching, training, and modeling</bold>. The second core consultation practice is the provision of coaching, training, modeling, reflection, and education on fostering mental health and social‐emotional development among both adults and children. Using these tools, the consultant supports the consultee to grow their own reflective capacity, confidence, and skill to foster positive social, emotional, and behavioral outcomes for the children in their care. In addition to having the knowledge and wherewithal to apply knowledge and skills, consultants emphasize the development of <emph>reflective</emph> capacity, defined by Spielberger et al. ([<reflink idref="bib42" id="ref101">42</reflink>]) as "self‐awareness and critical thinking about one's experiences, thoughts, and emotions in relationships with others." These supports are detailed within and align with the goals and service plan.</p> <p> <bold>Consultative stance</bold>. The final core consultation practice within Colorado's IECMHC model is the application of the consultative stance, which is the consultant's "way of being" in relationship‐based work with the consultee (Johnston & Brinamen, [<reflink idref="bib20" id="ref102">20</reflink>]). The consultative stance includes ten elements that are detailed in Table 8. These ten elements can be grouped into three categories:</p> <p></p> <ulist> <item> Elevating the consultee experience/expertise, which includes mutuality of endeavor, avoiding the position of the expert, and wondering instead of knowing</item> <p></p> <item> Understanding and integrating influencing factors, which includes understanding another's subjective experience, considering all levels of influence, hearing and representing all voices, and the centrality of relationships</item> <p></p> <item> Modeling and communicating support, which includes parallel process as an organizing principle, patience, and holding hope.</item> <item>lements of the consultative stance.</item> </ulist> <p> <ephtml> <table><thead><tr><th /><th>Element</th><th>Description</th></tr></thead><tbody><tr><td>Elevating consultee experience/Expertise</td><td>Mutuality of Endeavor</td><td>The consultant and consultee (family or provider) both contribute to the process by identifying the concern, mutually sharing their perspectives, developing hypotheses, showing willingness to participate in changes, and generating ideas for moving forward.</td></tr><tr><td /><td>Avoiding the position of the expert</td><td>The consultant relies on the relationships and a collaborative process with the caregivers in the child's life to build their capacity to deliver care and interventions in the context of the child's and caregiver's everyday activities.</td></tr><tr><td /><td>Wondering instead of knowing</td><td>Rather than providing their own opinions and solutions, the consultant asks questions to elicit the consultee's expertise and knowledge.</td></tr><tr><td>Understanding and Integrating Influencing Factors</td><td>Understanding another's subjective experience</td><td>The consultant listens to consultees (family, staff, etc.) and considers their personal context (values, attitudes, beliefs, practices) and personal experience/histories and how these influence their perception, relationships, and on‐the‐job actions/interactions.</td></tr><tr><td /><td>Considering all levels of influence</td><td>The consultant considers the influence that come to the consultee as part of an organization, such as program philosophies, peers and co‐workers, and others in the full context of an individual's work, such as in early care and education.</td></tr><tr><td /><td>Hearing and representing all voices</td><td>The consultant elicits information, hearing and voicing perspectives equally (especially the child's), and facilitating cooperation and collaboration.</td></tr><tr><td /><td>Centrality of relationships</td><td>The consultant holds the theoretical and developmental perspective that relationships and the interaction between caregiving adults and children have a primary role in the social/emotional development and mental health of young children.</td></tr><tr><td>Modeling and communicating support</td><td>Parallel process</td><td>The consultant takes the perspective that all relationships influence one another, and a positive experience in the relationship between the consultant and the consultee, positively influences the relationship between the consultee and the children in their care and their families.</td></tr><tr><td /><td>Patience</td><td>The consultant anticipates and takes the time to uncover, understand, and influence change, managing the pace of the collaboration between the consultant and the consultee(s).</td></tr><tr><td /><td>Holding hope</td><td>The consultant offers empathy and support to consultees through the consultant's belief in caregivers, families, and children and their capacity to grow, change, and be more effective.</td></tr></tbody></table> </ephtml> </p> <p>4 <emph>Source</emph>: Johnston, K. and Brinamen, C. ([<reflink idref="bib20" id="ref103">20</reflink>]). <emph>Mental Health Consultation in Child Care</emph>: <emph>Transforming Relationships among directors, staff, and families</emph>. Zero to Three Press.</p> <hd id="AN0187859956-16">Development of Colorado‐specific theory of change</hd> <p>Building on the core values and practices identified through the national scan, interviews, and development of the Essential Elements, the Colorado Lab conducted a theory of change articulation process with CDEC's IECMHC team. The resulting theory of change describes three primary pathways through which consultation promotes equity, reduces disparities in access to resources, and helps children thrive.</p> <p> <bold>Caregiver pathway</bold>. This pathway anticipates that changing ECE caregivers' attitudes and beliefs is foundational to changes in children's outcomes. When caregivers are committed to supporting children's mental health and social‐emotional well‐being, and have the knowledge, skills, and capacity to apply appropriate strategies, the result will be increased caregiver competence and efficacy, increased ability to structure classroom environments to support the well‐being of infants and young children, and improved child‐child and child‐adult interactions.</p> <p> <bold>Director pathway</bold>. This pathway anticipates that changing ECE directors' attitudes and beliefs is foundational to changes in children's outcomes. When directors are committed to supporting children's mental health and social‐emotional well‐being within their program, and have the knowledge, skills, and capacity to apply appropriate strategies that support infants/young children and the adults who care for them, the result will be improvements in program‐focused policies and procedures and in organizational climate.</p> <p> <bold>Family partnerships</bold>. This final pathway anticipates that increasing the capacity of ECE caregivers to partner with families and improving families' understanding of what happens in the classroom will increase family‐caregiver alignment of caregiving approaches and reduce caregiver‐family conflict.</p> <p>Cumulatively, the theory of change anticipates that these changes across caregivers, directors, and families work together to improve interactions and relationships among children and between children and caregivers, and to reduce provider stress and burnout. Ultimately, these outcomes will support improved mental health and social‐emotional well‐being of infants and young children, fewer behavioral concerns/incidents among children, reduced suspensions and expulsion in the early care setting, and increased workforce retention (Figure 2).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/BW6/01sep25/imhj70008-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="imhj70008-fig-0002.jpg" title="2 Colorado IECMHC theory of change." /> </p> <p></p> <hd id="AN0187859956-18">Development of implementation manual</hd> <p>The final step in Colorado's model development was the creation of a comprehensive implementation manual that: (<reflink idref="bib1" id="ref104">1</reflink>) provides an overview of IECMHC in Colorado; (<reflink idref="bib2" id="ref105">2</reflink>) unpacks the Essential Elements; (<reflink idref="bib3" id="ref106">3</reflink>) details workflow, data entry, and direct service requirements; and (<reflink idref="bib4" id="ref107">4</reflink>) describes the expected qualifications, skills, onboarding, and training of IECMH consultants. The implementation manual was developed in partnership with the advisory team and CDEC IECMHC program staff to supplement the Essential Elements and theory of change with more nuanced and thorough guidance on application. It is a detailed instruction manual for the field on how to put the Essential Elements of IECMHC into practice to achieve the intended outcomes outlined in the theory of change. Creation of this written manual is critical to implementing Colorado's IECMHC model with fidelity.</p> <p>Consistent with implementation science (Fixsen et al., [<reflink idref="bib14" id="ref108">14</reflink>]; Bauer et al., [<reflink idref="bib6" id="ref109">6</reflink>]), implementation of the Essential Elements with fidelity to the model is also fundamental to building evidence that the model can achieve its intended outcomes. As noted earlier, there is currently limited published research exploring both the implementation and outcomes of a statewide IECMHC model. The result is a research base that is not generalizable because the definitions of IECMHC vary so widely. Colorado's IECMHC model development process was the first step toward clearly articulating model components in order to demonstrate the model's effectiveness in achieving the kinds of outcomes articulated in the theory of change.</p> <hd id="AN0187859956-19">DISCUSSION</hd> <p>IECMHC is a rapidly expanding field of practice, particularly in the wake of the Covid‐19 pandemic, when traditional caregiving arrangements, professional practices, and child and family structures were disrupted. This case study of Colorado's work to clearly articulate an IECMHC model that can be implemented with fidelity and evaluated for effectiveness is an important step in building the evidence base for IECMHC. Colorado IECMHC leaders are working with consultants and supervisors across the state to put the model into action and continue to build evidence around its effectiveness as required by Colorado SB21‐137, the "Behavioral Health Recovery Act of 2021." To do this, the Colorado Department of Early Childhood has continued to partner with the Colorado Lab to develop and implement an evaluation strategy and aligned tools implemented in the regular course of consultation that will measure implementation fidelity and the outcomes articulated in the theory of change while supporting good consultation practice. This will be important for understanding how principles such as culturally and linguistically responsive approaches in IECMHC impact equity.</p> <p>Other states that are considering developing an IECMHC model can draw on the process that Colorado has followed. Those who have models developed but may not have yet tested their implementation fidelity or effectiveness may also benefit from Colorado's systematic approach to developing, implementing, and then testing their model. Colorado's efforts are still a work in progress. Next steps will test the fidelity of implementation and begin to measure how closely actual practices match those that are articulated within the model itself. The model development was the crucial first step in creating the groundwork that these next steps will build on.</p> <hd id="AN0187859956-20">ACKNOWLEDGMENTS</hd> <p>The authors are grateful to Alison Hargarten, Colorado's Early Childhood Mental Health Consultation Program Administrator during the time referenced in this manuscript, for her work in developing the underlying program documentation that provided the backbone for much of this work. This project was supported by the Preschool Development Grant Birth through Five Initiative (PDG B‐5), Grant Number 90TP0054, from the Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Office of Child Care, the Administration for Children and Families, or the U.S. Department of Health and Human Services.</p> <hd id="AN0187859956-21">CONFLICT OF INTEREST STATEMENT</hd> <p>The authors declare no conflicts of interest.</p> <ref id="AN0187859956-22"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref11" type="bt">1</bibl> <bibtext> The literature does not use one consistent definition for IECMHC. It is defined in varying ways across studies with most referring to descriptions of IECMHC coming out of the Center of Excellence for Infant and Early Childhood Mental Health and experts in the field such as Kadija Johnston and Charles Brinamen.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref12" type="bt">2</bibl> <bibtext> Results from this scan are a snapshot in time and may not reflect progress that some states may have made since the scan was conducted.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Note that Colorado's documents refer to IECMHC as simply "Early Childhood Mental Health Consultation" or "ECMHC." Even though the program does serve infants, ECMHC is used to align with other programs in the state.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref14" type="bt">4</bibl> <bibtext> This report is not a product of the Urban Institute. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Creating a Statewide Model of Infant and Early Childhood Mental Health Consultation: A Colorado Case Study
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Margaret+Franko%22">Margaret Franko</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-6771-1814">0000-0002-6771-1814</externalLink>)<br /><searchLink fieldCode="AR" term="%22Lindsay+Shields%22">Lindsay Shields</searchLink><br /><searchLink fieldCode="AR" term="%22Elly+Miles%22">Elly Miles</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2829-8163">0000-0003-2829-8163</externalLink>)<br /><searchLink fieldCode="AR" term="%22Lisa+J%2E+Schlueter%22">Lisa J. Schlueter</searchLink><br /><searchLink fieldCode="AR" term="%22Allison+Kallmann+Wegner%22">Allison Kallmann Wegner</searchLink><br /><searchLink fieldCode="AR" term="%22Clara+Prish%22">Clara Prish</searchLink><br /><searchLink fieldCode="AR" term="%22Kristin+Klopfenstein%22">Kristin Klopfenstein</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2457-8160">0000-0002-2457-8160</externalLink>)
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Infant+Mental+Health+Journal%3A+Infancy+and+Early+Childhood%22"><i>Infant Mental Health Journal: Infancy and Early Childhood</i></searchLink>. 2025 46(5):615-630.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 16
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: SourceSuprt
  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: Administration for Children and Families (DHHS), Office of Child Care (OCC)
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  Label: Contract Number
  Group: NumCntrct
  Data: 90TP0054
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Descriptive
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="DE" term="%22State+Programs%22">State Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Implementation%22">Program Implementation</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Caregivers%22">Child Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Early+Childhood+Teachers%22">Early Childhood Teachers</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Emotional+Learning%22">Social Emotional Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Consultation+Programs%22">Consultation Programs</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Colorado%22">Colorado</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/imhj.70008
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0163-9641<br />1097-0355
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The use of Infant and Early Childhood Mental Health Consultation (IECMHC) has grown dramatically over the past decade to support the skills and reflective capacity of adults who care for infants and young children birth to kindergarten entry. Research to date has shown promise for IECMHC to support children's social and emotional development. However, there is a gap in the published research that articulates how fidelity to a specific statewide IECMHC model impacts desired outcomes for adult caregivers or the infants and children they serve. This article, which articulates the process that Colorado used to develop its own IECMHC model, is the first step in filling this gap in the research. The step-by-step approach to model development can be used by other states undertaking similar efforts to create models that are geared toward a variety of settings, such as early education, home visitation, or health care. Colorado is beginning statewide implementation of the model that resulted from this process and will soon start evaluating the fidelity of that implementation. This process creates the groundwork for ultimately tying implementation of an articulated IECMHC model to outcomes for adults and the infants and children they care for.
– Name: AbstractInfo
  Label: Abstractor
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
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  Label: Accession Number
  Group: ID
  Data: EJ1482981
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1482981
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        Value: 10.1002/imhj.70008
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 16
        StartPage: 615
    Subjects:
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Early Childhood Education
        Type: general
      – SubjectFull: State Programs
        Type: general
      – SubjectFull: Program Implementation
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      – SubjectFull: Child Caregivers
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      – SubjectFull: Colorado
        Type: general
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      – TitleFull: Creating a Statewide Model of Infant and Early Childhood Mental Health Consultation: A Colorado Case Study
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