Creating a statewide model of infant and early childhood mental health consultation: A Colorado case study

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.

1. INTRODUCTION

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., 2021). 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, 2009). These skills support school readiness and later school success (Bagdi & Vacca, 2005). Research has demonstrated that caregivers’ own social and emotional well‐being and competencies can impact children's behavior and emotional regulation (Jeon et al., 2019) and likelihood of preschool expulsion (Silver & Zinser, 2020). 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.

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., 2015). 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., 2016).

Over the past two decades, experts in the field have provided an overall framework for IECMHC (Hunter et al., 2016; Johnston & Brinamen, 2006). Many states and localities across the United States have implemented some form of IECMHC (Center of Excellence, n.d.b). 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.

Key findings include

• Colorado has identified six principles of IECMHC, which include: (1) building adult capacity; (2) creating relationships with consultees; (3) prevention and early mental health promotion; (4) cultural and linguistic responsiveness; (5) strength‐based solutions; and (6) professional growth.

• The Essential Elements of Colorado's IECMHC model define three core consultation practices: (1) collaborative development of data‐driven goals; (2) provision of relevant coaching, training, and modeling; and (3) use of the consultative stance.

• The ten elements of the consultative stance can be grouped into three categories: (1) elevating the consultee experience/expertise; (2) understanding and integrating influencing factors; and (3) modeling and communicating support.

Relevance and Key Findings

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.

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., 2023). 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.

2. LITERATURE REVIEW

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.

2.1. Social‐emotional development

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., 1995). Since then, researchers have reaffirmed its important role for children in navigating school and life (Bagdi & Vacca, 2005; National Research Council and Institute of Medicine, 2000).

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., 2015). 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., 2018). 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., 2019). 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, 2020).

2.2. Infant and early childhood mental health consultation

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., 2016), approaches to consultation (Johnston & Brinamen, 2006), and professional competencies (Center of Excellence for Infant & Early Childhood Mental Health Consultation, n.d.a.; Korfmacher, 2014; Office of Head Start, The National Center on Health, n.d.) 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., 2016).

2.3. Implications of IECMHC for children and caregivers

The evidence base for IECMHC¹ 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., 2010). 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., 2022). Silver et al (2023) 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., 2016) and with multi‐ethnic populations in urban settings (Natale et al., 2022). Others have identified associations between IECMHC and reductions in suspension and expulsion (Silver & Zinsser, 2020; Miles et al., 2021), improvements in caregiver‐child interactions (Amini Virmani et al., 2013; (Conners‐Burrow et al., 2013), and child and peer behaviors (Gilliam et al., 2016; Reyes & Gilliam, 2021).

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., 2020), while another found a significant decrease in caregiver‐child conflict scores for Black children after IECMHC services with caregivers (Shivers et al., 2022). 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., 2021; Novoa & Malik, 2017; Zeng et al., 2021).

2.4. Fidelity of implementation

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., 2015). 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., 2012). 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.

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 (1) structuring the process for consultation (e.g., collaboratively defining vision for consultation, supporting the consultees as they implement); (2) building and nurturing equitable relationships with consultees; (3) fostering consultee capacity to think and act in new ways; (4) empowering consultees to enhance equity in their roles; and (5) attending to consultant skills, self‐care, and self‐awareness (Davis Schoch et al., 2024). 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.

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., 2011). 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., 2023). 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., 2021). Two randomized control trials (RCT) in Connecticut (Gilliam et al. 2016) and Ohio (Reyes & Gilliam, 2021) 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.

3. BUILDING CONSENSUS TOWARDS A COLORADO IECMHC MODEL

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, 2020). 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).

FIGURE 1.

Model development process.

3.1. National scan of state infant and early childhood mental health consultation models

The initial step in model development began with a national scan of other states’ IECMHC models² (Miles & Schlueter, 2020). 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.

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).

TABLE 1.

2019 State‐reported Status of IECMHC Models.

Model developed and evaluated	Model developed/no evaluation completed	Model in development	No model/Insufficient information to assess model status
Arizona Arkansas California (San Francisco) * Connecticut District of Columbia Louisiana Maryland Michigan Nebraska (Omaha) * New York (New York City) * Ohio Oregon (Portland) * Pennsylvania	Alabama Illinois Kentucky Massachusetts Minnesota New Hampshire Rhode Island Virginia	Colorado Florida Maine Missouri Montana South Carolina Texas Utah Washington Wisconsin	Alaska Delaware Georgia Hawaii Idaho Indiana Iowa Kansas Mississippi Nevada New Jersey New Mexico North Carolina North Dakota Oklahoma South Dakota Tennessee Vermont West Virginia Wyoming

^*IECMHC models in these states were in place in the specified city only.

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., 2016). 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.

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.

TABLE 2.

Tools and trainings incorporated into IECMHC models.

Evidence‐based tool or training	Number of states incorporating in model (n = 21)
Pyramid model	13
Reflective supervision/consultation	9
Facilitating attuned Interactions (FAN)	7
Conscious discipline	5
Incredible years	4

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.

TABLE 3.

Reported frequency, intensity, and duration within state IECMHC models.

	Frequency	Intensity	Duration
Child‐focused services (n = 21)
Most common	1–2 times/week	1–4 h	Varied/no limit
Range	2x/week‐every 4 months	1–8 h	2–27 months
Classroom‐focused services (n = 20)
Most common	1x/week	1–2 h	1–3 months
Range	2x/month‐1x/week	2–12 h/month	1–27 months
Program‐focused services (n = 4)
Most common	1–2 times/week	1–3 h	1–6 months
Range	1x/week‐variable amounts	1 h‐variable amounts	1–12 months

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.

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.

3.2. Development of statewide dosage expectations

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., 2020). 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.

TABLE 4.

Colorado's recommended dosage expectations.

	Frequency	Intensity	Duration
Child‐focused services
Minimum	1x/month	6 h/case	2 months
Maximum	3x/month	60 h/case	6 months
Classroom‐focused services
Minimum	2x/month	12 h/case	3 months
Maximum	3x/week	120 h/case	9½ months (academic year)
Embeddeda	N/A	8 h/week	N/A
Program‐focused services
Minimum	1x/month	2 h/month	Brief consult
Maximum	5x/week	12 h/month	12 months (option to renew)
Embedded	N/A	24 h/week	N/A

Source: Bellomo et al., 2020 ; ^a “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.

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., 2020). 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.

3.3. Interviews with the infant and early childhood mental health consultation workforce

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, 2021).

The interview protocol focused on three main topics: (1) what components of consultants’ practice might be considered core or “Essential Elements” of IECMHC; (2) what a day in the life of an IECMH consultant looks like at each distinct service level (program‐, classroom‐, and child‐focused consultation); and (3) 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, 2021):

Essential elements of IECMHC. According to consultants and supervisors, the following are at the heart of IECMHC:

• A focus on supporting the skills and capacity of adults who care for infants and young children.

• Relationship‐building between consultants and clients.

• Providing positive feedback and emphasizing client's expertise.

• Building the reflective capacity of clients.

• Providing guidance and modeling of effective practices and approaches.

Levels of service. 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.

Service duration. 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.

3.4. Colorado's essential elements of infant and early childhood mental health consultation

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.

TABLE 5.

Essential elements: Principles.

IECMHC is focused on building the capacity of adults. It is not about “fixing kids.”
IECMHC is based on strong, positive relationships with adults providing care for young children.
IECMHC is focused on prevention and early mental health promotion.
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.
IECMHC is strengths‐based and grounded in equity. It builds upon the abilities and positive qualities of all children, families, and early childhood professionals.
IECMH consultants are supported through professional development and reflective supervision to deepen their practice.

TABLE 6.

Context and structure.

Consultants work with adults providing care for children age birth to 6, including the prenatal period.
Consultation occurs in settings where children learn and grow.
Consultants may be embedded within a program/organization or set of organizations.
Consultants follow program guidance on frequency, intensity, and duration of service delivery.

TABLE 7.

Colorado consultation activities.

Activities	Description
Coaching	Supporting and guiding consultees in implementing action steps toward their goals
Training	Providing individual or group training on a topic related to social emotional development or mental health
Modeling	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
Reflection	Modeling wondering and providing space to debrief the consultee's actions, emotions, influences, and perspectives
Education	Providing written or verbal information about a goal‐relevant topic

Source: Early Childhood Mental Health Consultation (ECMHC) Colorado Implementation Manual.³.

Principles. 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: (1) building adult capacity; (2) creating relationships with consultees; (3) prevention and early mental health promotion; (4) cultural and linguistic responsiveness; (5) strength‐based solutions; and (6) professional growth.

Building adult capacity . 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., 2019; Conners Edge et al., 2021). 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.

Creating relationships with consultees . 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., 2020; Shea et al., 2022). 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.

Prevention and early mental health promotion . 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.

Cultural and linguistic responsiveness . 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.

Strengths‐based solutions . 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., 2022; Shahmoon‐Shanok & Geller, 2009). 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.

Professional growth . 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.

Context and structure. The context and structure section of the Essential Elements provides additional details about: (1) age ranges served; (2) service settings; (3) consultant relationships to settings; and (4) dosage.

Age ranges served . 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, 2023), but based on definitions articulated by national early childhood organizations (Zero to Three, 2017) 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.

Service settings . 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.

Relationship to setting . 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.

Dosage . 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.

Consultation practices. The Essential Elements define three core consultation practices: (1) collaborative development of data‐driven goals; (2) provision of relevant coaching, training, and modeling; and (3) use of the consultative stance.

Collaborative development of data‐driven goals . 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.

Coaching, training, and modeling . 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 reflective capacity, defined by Spielberger et al. (2022) 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.

Consultative stance . 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, 2006). The consultative stance includes ten elements that are detailed in Table 8. These ten elements can be grouped into three categories:

• Elevating the consultee experience/expertise, which includes mutuality of endeavor, avoiding the position of the expert, and wondering instead of knowing

• 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

• Modeling and communicating support, which includes parallel process as an organizing principle, patience, and holding hope.

TABLE 8.

Elements of the consultative stance.

	Element	Description
Elevating consultee experience/Expertise	Mutuality of Endeavor	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.
	Avoiding the position of the expert	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.
	Wondering instead of knowing	Rather than providing their own opinions and solutions, the consultant asks questions to elicit the consultee's expertise and knowledge.
Understanding and Integrating Influencing Factors	Understanding another's subjective experience	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.
	Considering all levels of influence	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.
	Hearing and representing all voices	The consultant elicits information, hearing and voicing perspectives equally (especially the child's), and facilitating cooperation and collaboration.
	Centrality of relationships	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.
Modeling and communicating support	Parallel process	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.
	Patience	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).
	Holding hope	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.

Source: Johnston, K. and Brinamen, C. (2006). Mental Health Consultation in Child Care: Transforming Relationships among directors, staff, and families. Zero to Three Press.

3.5. Development of Colorado‐specific theory of change

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.

Caregiver pathway. 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.

Director pathway. 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.

Family partnerships. 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.

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).

FIGURE 2.

Colorado IECMHC theory of change.

3.6. Development of implementation manual

The final step in Colorado's model development was the creation of a comprehensive implementation manual that: (1) provides an overview of IECMHC in Colorado; (2) unpacks the Essential Elements; (3) details workflow, data entry, and direct service requirements; and (4) 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.

Consistent with implementation science (Fixsen et al., 2005; Bauer et al., 2015), 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.

4. DISCUSSION

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.

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.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Franko, M. , Shields, L. , Miles, E. , Schlueter, L. J. , Kallmann Wegner, A. , Prish, C. , & Klopfenstein, K. (2025). Creating a statewide model of infant and early childhood mental health consultation: A Colorado case study. Infant Mental Health Journal, 46, 615–630. 10.1002/imhj.70008