Early intervention has been proven to be effective for a number of behavioral and developmental disturbances. However, many families face barriers in obtaining behavioral health services for their young children, including financial barriers, as well as the stigma that is often associated with mental health treatment. To meet the special needs of infants, toddlers, and preschoolers from lower-income families in the Pittsburgh area, the Theiss Child Development Center provides inclusive mental health services in a day care setting.

The center is part of the Matilda H. Theiss Center, which is located in a mixed-income inner-city public housing community and is also home to a health clinic run by the University of Pittsburgh's department of family medicine. The Theiss Child Development Center, a division of Western Psychiatric Institute and Clinic and of the University of Pittsburgh Medical Center, has been in continuous community service for more than 35 years. During the past 13 years, the center has modified existing programs and implemented clinical ones, including programs to serve children who have special needs.

The Theiss Child Development Center represents the highly successful implementation of solid child development concepts and child psychiatric practices. The center includes a day care program that serves approximately 90 children aged six weeks to six years who come from diverse socioeconomic backgrounds, including community families, mothers entering the workforce, and those who are in training as a result of welfare reform. The Theiss Child Development Center provides a positive and accepting learning environment to encourage children's curiosity and give them the confidence to pursue knowledge. The day care program also includes an early childhood education program designed to promote intellectual, social, emotional, and physical development.

Embedded within this day care setting are two clinical programs that operate six hours a day, five days a week. The first is a licensed preschool partial hospital program for children between the ages of three and six years. This program has a capacity of 24 children. The second clinical program is a therapeutic nursery program known as the Program for At Risk Kids (PARK) for children aged six weeks to three years who were born to women with serious psychiatric disorders or women who used drugs or alcohol during pregnancy. This program's capacity is 12 children. Both treatment programs have been fully operational since 1995 and serve children with severe emotional and behavioral problems. The children often have significant developmental delays. Some of these children are at risk of difficulties because of the effects of parental psychiatric problems or substance abuse. Conversely, for some parents, the stress of parenting children who have multiple significant problems has interfered with their own functioning by worsening their symptoms, causing them to postpone or miss their own treatment, or to miss so many days of work that they lose their job. These children receive developmentally appropriate intervention services to facilitate the realization of their full potential. Because most of the children in the center's programs come from families that pass the income test for subsidized meals, clients are provided with nutritionally balanced meals on a daily basis. Approximately 36,000 meals are served each year.

The fact that children who are developing "typically" attend the day care program alongside those who are enrolled in the treatment programs means that there is a natural comparison group for measuring outcomes. The typical children also provide an environment of appropriate social and linguistic behavior for the children in the clinical programs. The fact that the setting resembles a typical child care environment reduces the stigma that families may experience as a result of obtaining mental health services for their young child. Parents sometimes tell their friends that their child is enrolled in the day care. Some of the children experience sufficient therapeutic improvement to enable them to graduate from the treatment program to day care.

Prevention and early intervention studies have shown that children are effectively treated in programs that include a parental component. Thus the Theiss Child Development Center stresses the need for parental participation in group or individual educational sessions. To facilitate participation, the center tries to accommodate parents' schedules and special needs, including extended hours. For example, parents who work shifts need flexible hours of service. Parents and guardians of children who are enrolled in the clinical programs participate in the treatment planning process, in individual child-centered parent counseling, and in parents' groups that focus on skills building, educating parents as advocates, and support. Also, family members are represented on the center's advisory board.

Many of the families who attend the child treatment programs have multiple problems but few resources. For example, of the first 44 children enrolled in the therapeutic nursery program, 11 became homeless. To help address the special needs of the families who attend the Theiss Child Development Center, the center joined forces with four other community agencies to create a continuum of care for mothers who are in recovery and for their children—an Afrocentric drug and alcohol treatment agency (House of the Crossroads), a community-based case management and linkage agency (Hill District Community Collaborative), a women's shelter (WomanSpace East), and the Housing Authority of the City of Pittsburgh—known as the Partner's Continuum and currently in its seventh year of operation. The Theiss Center serves as the fiduciary agent that links families to multiple community resources.

The strength of the center lies in its staff, many of whom live in nearby neighborhoods, including the Hill District. The staff constitute a group of professionals who function as a multidisciplinary team. Disciplines represented on the team include child psychiatry, developmental and school psychology, early childhood education, child development, pediatrics, and social work. Staffing has been stable, and new recruits are carefully assessed for their ability to work with the existing team. Approximately 30 staff serve the children and their families. Staff-child ratios range from 1:3 for infants to 1:6 for children of preschool age. At least five child psychiatry residents rotate through the program each year.

The center allocates two hours for psychiatric consultation per week for every five children enrolled. The therapeutic nursery program and the preschool partial hospital program each have a medical director who is a psychiatrist and who is responsible for clinical oversight and programming. Crucial roles of the medical directors include ongoing staff training by joint review of progress across all domains during weekly treatment meetings; psychiatric assessment of the children; medication management (in limited cases for children aged three to six years); child-centered parent therapy and individual child therapy and supervision; and managed care review as needed. Both medical directors are heavily involved in training child psychiatry fellows, the next generation of child psychiatrists, to work with young children and their families.

In addition, two master's-level clinicians are responsible for directing parent services, including helping parents negotiate the managed care environment, enhancing parent effectiveness, and linking families to other resources in the community. Up to 36 families are assigned to the two specialists in parent intervention. Approximately 120 separate families are served each year in either the clinical or nonclinical programs.

Every major age grouping of children is assigned to a developmental therapist. The program's developmental therapists hold a minimum of a bachelor's degree in early childhood education, early childhood special education, child development, or a related human service discipline. The ratio of adults to children varies according to the age of the child. Children in both the clinical and nonclinical programs are served by these therapists.

Other important staff positions include two cooks, who provide a minimum of two meals and one snack each day to each child in the center; a full-time psychologist, who serves as the clinical administrator; a full-time coordinator of child development services; four clerical and administrative support staff; and foster grandmothers and volunteers.

One of the challenges the center has faced has been the need to support staff members who had traditionally worked only in nonclinical settings. In anticipation of building the clinical programs, the child psychiatrist, the clinical administrator, and the coordinator of child development services conducted a review and subsequently developed a training program to meet the needs of the children in the clinical programs. The training program covered topics such as presenting to a treatment team, principles of behavior management, note taking, and the medical directors' reporting requirements. Treatment protocols were developed for such problems as aggression, noncompliance, and high levels of activity to help ensure a consistent approach to the most frequently encountered early childhood behavioral problems. In addition, three-day all-staff inservice training on various topics is held once a year.

The center was one of the first of its kind in the Pittsburgh area and was the first in Pennsylvania to receive approval for a therapeutic nursery program. It has overcome funding obstacles to weave together multiple funding sources and has been able to justify a continued high level of support by demonstrating the effectiveness of its programs. The center's current funding streams total slightly more than one million dollars. The following funding sources support the program: managed care mental health funds (61 percent), the Department of Public Welfare and parents' day care fees (14 percent), foundation funds and charitable events and donations (14 percent), the Department of Housing and Urban Development (6 percent, for parent support and a van and driver), and the Department of Education and the Early Head Start Program (5 percent, for nutritional support and playground equipment).

A number of developmentally appropriate rating scales are used to track the progress of the children. Social, self-care, and cognitive skills have been shown to respond well to the therapeutic nursery program (PARK). About a third of older children enrolled in the center's partial hospital program are discharged from the program because of clinical improvement and make the transition to regular kindergarten classrooms. The other two thirds are placed in special education programs. Attendance has been demonstrated to be the most significant predictor of successful treatment outcome. In a recent survey of parents of children enrolled in either the clinical programs or the nonclinical day care program, the results were uniformly positive. The center has demonstrated, with psychiatric leadership, that a day care program that serves "typical" children can be transformed into a high-quality provider of clinical services.

For more information, contact Vaughan Stagg, Ph.D., Director, Theiss Child Development Center, 373 Burrows Street, Pittsburgh, Pennsylvania 15213; phone 412-383-1575; fax 412-682-4640; e-mail, staggv@msx.upmc.edu.