Professional Resource

Healing the Young Child by Helping the Caregiver: Implementing an Intergenerational Approach

Sep 8, 2020

Virginia “Ginger” Bial, Andrea Hazen, and Kristen Sylvester, Rady Children's Hospital, San Diego, California

This article describes the development and implementation of an integrated early childhood mental health and caregiver support program that uses a transdisciplinary approach to engage families and systems, maximize service efficiency, and ultimately create a next generation of safer families. A case example illustrates a family’s journey through services, and a range of perspectives, including leadership and direct service staff, are presented to illuminate the impact of the services. The authors hope to inspire and encourage other early childhood programs to address the needs of caregivers directly in order to continue to move toward an intergenerational model of healing.

When she came to the office for her son’s intake at KidSTART‘s mental health program, my first impression of Ben’s1 mother, Carla, was, “Wow, this mother is on top of things!”. Carla presented with a list of topics to discuss, and she shared openly about what Ben needed from services. As we talked about Ben’s life experiences, Carla alluded to her own experiences and how those affected her parenting. She shared about her guilt for using substances during pregnancy and her worry that this had affected her son permanently. When I asked about her own well-being, Carla steered the conversation away from herself and shared that she was committed to doing whatever it took to help Ben make progress in treatment. Carla seemed hesitant to meet alone with me for the purpose of connecting and exploring how she, herself, was doing. She appeared anxious and answered with one- or two-word responses to my questions, much different than when talking about her son. I listened and validated her challenges, and over the course of the conversation, she began to share more. We identified together that she was struggling with feelings of guilt about her past substance use, which she had previously mentioned, but also was struggling with her choice to leave an abusive relationship. She talked about how her life “went down the tubes” when her father left when she was 17 years old, and that she felt Ben’s life was ruined as well because his father was not around. She talked about her mother’s criticism of her parenting, and how she and her brother constantly argued about the best way to manage Ben’s needs. Carla was able to identify how anxiety and self-criticism were coming up for her on a daily basis in all of her interactions and were getting in the way of doing the things that she felt were most important for her and her family. We talked about what might help her and decided I’d connect her to a parent care coordinator, for support with resources, and to the psychoeducation group, to help her gain confidence in her parenting skills and connect with others in similar situations.

Carla’s story illustrates how the experiences of children, particularly young children, are intertwined with those of their caregivers, and that honoring this interconnectedness plays a critical role in effective treatment. This article will describe an early childhood mental health program that initially started with a dyadic focus on young children and their families, but then identified the need to grow, transition, and augment services in order to more directly meet the needs of caregivers.

Caregivers with young children often face a variety of personal stressors and demands which impact their ability to parent the way they might intend.

The KidSTART program was established at Rady Children’s Hospital San Diego through a contract with the County of San Diego Behavioral Health Services, First 5, and Child Welfare Services in 2010. The goal was to create a continuum of developmental and mental health services to assess and treat extremely vulnerable young children from birth to 5 years old with complex needs, whom we know to be at the highest risk for child abuse and neglect, including death related to child maltreatment (Children’s Bureau, 2020). Within this collaborative program that includes mental health services, developmental services, and service coordination, KidSTART’s early childhood mental health therapists at the Chadwick Center for Children and Families provide trauma-responsive services to children and their families using evidence-based modalities.

For years, the mental health team watched children get better as the needs of the caregivers went unmet. Young children’s progress in treatment is often closely tied to that of their caregivers’ well-being, which is especially true when caregivers are struggling with their own mental health, trauma, or substance abuse challenges. The caregiver’s challenges contribute to the complex social–emotional and developmental needs of the children, and the immense stress on caregivers can often overwhelm them. Although caregivers were integrated into children’s treatment and received support from the child’s therapist, we recognized that additional services were needed in order to fully address the range of needs presented by different types of caregivers, including birth parents, grandparents, and nonfamilial resource parents. We, as leaders, began sharing these concerns with county representatives and in community meetings, offered local trainings on the subject matter, and documented the importance of the system supporting the child, the child–caregiver relationship, and the caregiver. These services for caregivers were essential if we truly wanted young children to gain the most from their time in treatment and for them to sustain their gains after treatment ended. The County of San Diego agreed; in 2015, the Health and Human Services Agency’s Behavioral Health Services, through the Innovations component of California’s Mental Health Services Act (MHSA), funded an integrated program called the Caregiver Wellness Program, to offer screening, assessment, community linkage, and group therapy directly to caregivers with a behavioral health need. The years of promotion and education with a collective, steady voice paid off. Over time, and through a collaborative effort with Rady Children’s Hospital San Diego, the county was able to determine that this need would be an ongoing part of a larger landscape of needs and worked to identify how it may align with specific available funding sources. Local early childhood mental health experts validated the importance of the role of the caregiver’s health, and in 2015 when the next 3-year cycle of MHSA Innovations funding became available, the county moved forward with implementation. This was the first time that we were aware of when transdisciplinary services for multiple generations of family members would be able to be offered under the same roof in our county. We were ecstatic! The caregivers would no longer have to tell their family’s story again and again. They would not have to re-engage, build trust, and establish rapport again with another behavioral health provider. They did that already at KidSTART. They met the team, they typically trusted the team, and now the team would extend services to their needs, not only those of their young children.

The initial excitement quickly turned into focused energy to build an entire program for adults alongside a program created for young children. Core areas that needed to be developed included the eligibility criteria; referral pathway; registration process; screening, assessment, and treatment service flow; staff training and supervision plan; documentation standard; data tracking procedure; and evaluation protocol. Implementation began within 60 days of funding. Over the course of the next 18 months, the program design was reconfigured several times because outcomes were not as expected. Caregiver participation was minimal, and staff burnout and secondary traumatic stress were on the rise. We did not give up hope and with time, perseverance, and much humility, KidSTART’s mental health program was transformed into the impactful integrated program that stands today.

1 All names and identifying information have been changed.