Childhood Mental Health in the Community

Nathaniel Donson, M.D.

The work I describe here is an extension of a twenty year interest in using psychoanalytically informed principles for early childhood mental health intervention using available routes within my local community. Working onsite (usually voluntarily) at community day-care centers, Headstart programs and nursery schools, I have offered weekly services to center directors and caregivers regarding children and families about whom they are concerned.

The first step has always been to approach and converse with a center director in order to sound out his or her interest in having a psychoanalytic mental health consultant pay regular visits to the program. This is an immensely complex and challenging part of the process and fails as often as it succeeds. Its success depends primarily on the comfort and motivation of the director, as well as his or her willingness to encourage exploration of the developmental needs of children and families at the center. At times, an interested director may be in need of help to deal with difficulties with staff, or will agree after several conversations to a trial period with me or another mental health professional as a potential consultant. Sometimes I have been sent to a director by a board member or friend. After clearing my presence at a given center with the director and governing board, I then begin spending several hours per week at the site.

Once a format for my ongoing presence there has been worked out (even provisionally), by the director, we look for ways of meeting with, and/or announcing my presence there to the staff and parents. At the beginning of each school year a letter is sent out, and I am usually asked to be at the new parents' orientation meetings. At a regular weekly time, I meet first with the director, occasionally interview worried caregivers or parents, and usually am asked to observe children within the classroom who are of concern to the director and staff. Follow-up meetings then take place on an informal or as-needed basis.

There are also regular monthly consultation meetings with the entire staff at which certain children may be discussed and followed, sometimes through the school year. Confidentiality, especially about private matters regarding a child or his/her family, is always well established by agreement with the center. All members of the staff as well as a particular child's caregivers from previous or subsequent years benefit from these discussions. In addition, there are regularly scheduled monthly parents' meetings at which a previously announced topic is discussed ("Sibling Rivalry," "Aggression—Whose?" etc)

I do not accept private referrals from a center where I am consulting, but may cross-refer to other colleagues who are interested in and skilled in therapeutic work with very young children. (Currently, Larry Shaderowfsky is doing similar work at a nearby New Jersey nursery school.) So far, I have done such on-site consulting work in three different settings for periods of four or more years: a single parent federally sup-ported day care center, a large (500+ children) private nursery school, and currently a co-op pre-school and kindergarten.

Aside from spending on-site time in community childcare facilities, ten years ago I started a monthly interdisciplinary discussion group which we called "Intervention with Under-Fives." Membership, which peaked at twenty four com-munity professionals interested in disturbances of development in young children, included teachers, therapeutic and day nursery directors, learning and language specialists, and mental health profes-sionals from various analytic and non-analytic disciplines. We met regularly for seven years and considered papers, case presentations, classroom experiences with young children, and instructional videotapes; we also invited guests who presented in their own specialized areas of early childhood re-search or intervention.

Using a similar model, I have organized three additional discussion groups, or "Pre-School Consultation Workshops" composed of directors of early childcare centers and the mental health professionals who spend time in these settings. These were organized as open-ended monthly discussion groups in which both the director and consultant could learn together and present and discuss evolving consultation programs which were taking place at their centers. Over the years, at least twenty director/consultant pairs have taken part in these workshops. The original workshop lasted four years; the second, started under the auspices of a community mental health center, lasted two years until funding ran out. The third group is still going strong after four years.

For the past two years, I have met with the home visiting counselors in a program called "Healthy Families." This is a hospital based state and federally funded intensive mother/infant intervention program with dozens of similar units operating in this state (New Jersey) and nationally. It is marketed for purposes of funding as a "child abuse intervention program." Our discussions touch on intervention strategies with very high risk mothers and infants which have been developed by Fraiberg, Stern, Greenspan, Emde and others, and they incorporate developmental and psychody-namic psychoanalytic principles and clinical the-ories. My own supervision is weighted heavily on countertransference issues and is clearly appre-ciated. Our discussions have turned out to be a considerable hedge against staff burnout in this immensely difficult work. I am on the program's advisory board, and periodically participate in statewide conferences about this work.

Such time is well spent. My consultation work is easily the most enjoyable part of my week, gets me out of the office into settings bursting with energy and activity, has helped me to become well known in my community as a professional interested in early intervention, and has added immeasurably to my clinical skills in thinking through some very challenging problems with young children and their families. I am certain that referrals to my practice have remained at acceptable levels because of these efforts, despite the fact that managed care has siphoned off considerable numbers of young children in need of therapeutic help. I currently have three children in three times weekly analytic therapy, and am hopeful that sustaining levels of referral will continue to be derived from this community outreach work.