Team-Based Care in Early Childhood Mental Health: A San Francisco Story
At The Primary School, our ambition is to create a school model that brings together systems and groups that would otherwise remain siloed, creating a team of families, educators, medical and mental health providers, with children and parents at the center. Integration of supports and team-based care means that families can experience systems — namely those designed to support physical, mental, and emotional health — not as obstacles to overcome, but as places of agency and healing.
Over the last two years, we have had the opportunity to collaborate with Wu Yee Children’s Services (Wu Yee) as a learning and resource partner to build a multi-tiered system of supports for mental health at their Kirkwood Child Development Center (Kirkwood), located in the Bayview district of San Francisco.
San Francisco is the birthplace of early childhood mental health consultation (ECMHC), a model that, in the 30 years since its creation, has been affirmed nationwide as a proven method to grow adults’ capacity to support children’s social and emotional development. ECMHC is delivered by mental health professionals, and strongly emphasizes capacity-building. This includes capacity-building of adults caring for young children — parents, educators, and caregivers — as well as capacity-building of early care and education programs, through building nurturing environments that promote emotional wellness.
Though the core relationship-based principles of ECMHC are widely agreed upon, there is great diversity when it comes to on-the-ground implementation and practices of ECMHC, and in fact, ECMHC encourages customization to meet different needs and fit different contexts. Kirkwood has taken this encouragement to heart, developing an ECMHC program suited to the children and families they serve and those families’ particular circumstances.
Leveraging an opportunity to innovate and learn within San Francisco’s early childhood mental health landscape, The Primary School partnered with Wu Yee in 2018 to create a new role at the Kirkwood site: the Family and Child Wellness Coach, a role filled by Dr. Renée Aguilar. “Dr. Renée”, as she is fondly referred to throughout Wu Yee, was tasked with leading the collaborative work of designing a model for a multi-tiered system of supports (MTSS) at Kirkwood and other Wu Yee sites to address the differentiated needs of children, families, and classrooms. Wu Yee and The Primary School also invited Seneca Family of Agencies, a provider that The Primary School had been working with in its East Palo Alto school, to be a design partner and service provider for the newly designed MTSS model.
Wu Yee, The Primary School, and Seneca intentionally took an iterative and bottom-up approach to designing the mental health model at Kirkwood to encourage collaboration and staff voice. The team solicited input from directors and managers, and all Kirkwood teaching and support staff were invited to participate in focus groups in order to bring practitioner perspective into the design process. This input was then used to inform bi-weekly design sessions with a core team of staff from Kirkwood, The Primary School, and Seneca. The resulting MTSS model was based on Dr. Bruce Perry’s Neurosequential Model, emphasizing deep collaboration across teachers, coaches, families, and clinicians, and combining consultation with direct service (therapy and playgroups).
Kirkwood staff and Seneca staff partnered in recruiting and interviewing clinicians who would be a good fit for the site, the team, and the model. The team hired Aditi Uttawar, whose strong experience in early childhood settings and background in somatic psychology with a concentration in dance movement therapy made her well suited for clinical work within Kirkwood’s MTSS system. In May 2019, Aditi began her work as a clinician at Kirkwood, presented to families and staff from the outset as the Social Emotional Learning Coach in order to reduce any reservations about accessing her supports. In the ensuing year, Aditi has become a deeply valued part of Kirkwood. Says one teacher, “She comes into the classroom at consistent times, and she helps me out so much. The kids just love her.”
We interviewed Aditi about her work at Kirkwood, including how COVID-19 has affected her practice.
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What does a typical week look like for you?
I’m onsite 2.5 days per week for 20 hours. Tuesday and Thursday are full days on site, Fridays are half days. In the mornings, I have group and individual therapy, observations (with a focus on students that come up in the Child Review Team meetings), and teacher support or coaching where I model interventions in the classroom.
Tuesday afternoons, during kids’ naptime, are Child Review Team meetings. This is where the teachers and staff come together once a month for one hour to go through medical records, dental records, academics, and social-emotional learning (SEL) development for each child. This is a preventative way to check in on kids, catch any behaviors, and shifts in family, health, and other changes.
If it comes up during this meeting that a student needs extra support, then we will hold a Student Strengths Support meeting and invite parents to participate. These happen on Thursday afternoons.
I also hold teacher office hours in the afternoon, which is a consistent time where I consult on specific teaching strategies, and do elbow coaching [verbal coaching in the classroom, in real time].
You provide therapeutic services on-site, including family therapy, more intensive one-to-one or dyadic therapy. Are families open to these services?
Families at Kirkwood have specifically sought out family therapy. Currently, I have family therapy sessions with three different families. We talk about family goals, and what they want to achieve. The theme has been more attunement with their child. I have a caseload of six individual clients, two of whom are from the same family.
What kinds of parent workshops do you host throughout the year?
I’ve focused on attunement or attachment. I’ve talked about the book The Whole Brain Child by Daniel Siegel. I try to incorporate an experiential component and a psychoeducation component into these workshops. For example, sometimes I role-play the child.
One of the workshops was centered around how to “connect and redirect” instead of “command and demand.” I highlighted the importance of coming down to the level of the child, both physically and verbally. I demonstrated these principles by initially towering over a child and speaking in a loud, authoritative, biting voice, and then kneeling down next to a child and speaking softly with a soothing rhythm. Finally, I role-played a child and asked for participation from parents and caregivers.
Prior to coming to Kirkwood, what did your training and experience consist of? What do you think helped you succeed in your role at Kirkwood?
My training was in somatic psychology with a concentration in dance movement therapy. As people we
embody and feel different movements and textures. Physiological changes in the body level give access to choice and regulation.
I think my training was very valuable to this age group of infants and toddlers. The focus is on nonverbal communication. When you get older, it’s all about talking, but young kids have trouble expressing themselves verbally. I went to school to learn about these non-verbal communication styles.
As a testament to efficacy of a “relationships first” approach, during the initial weeks of San Francisco’s shelter-in-place order, most of the families and children receiving individual and family therapy from Aditi continued to show up to their sessions virtually - a testament to the value they found in that support and relationship. In fact, Aditi talked about how helpful it was to see the natural settings of children who spend time in different homes and work with different caregivers and siblings via teletherapy.
How has COVID-19 affected your work?
Renee, Jonathan [Seneca Director of School Partnerships and Aditi’s clinical supervisor], and I have SEL planning sessions every two weeks, and we worked collaboratively to think about how to keep providing services during this time.
I’ve been creating SEL videos, so children can see a familiar face delivering the content. I’ve been using A Little Spot of Emotion Box Set and my home office and a play space in my house to film the videos, to talk about all kinds of different emotions. This is an indirect service, so parents and teachers can put on a video that Ms. Aditi has done.
In the spring, I held individual/family sessions over Zoom, Facetime, Whatsapp, Duo - pretty much any platform available, and I provided supports to families who wanted them. In the fall, I will still be working from home and we’re talking about setting up a laptop in classrooms so she can video call in and still do observations.