It's a Friday afternoon at the Renaissance Children's Center in Lakewood, and six-year-old Demetrey Fulks is out of control again. First he hit a boy over the head with a plush Pokémon toy. Then he ordered another student to bring him his Game Boy. Now he's play-fighting with some other kids, but it looks like it hurts.
For a child with an such angelic face, Demetrey punches hard.
Five boys and one girl, all in kindergarten and first grade, come to this classroom every day after school. This week is spring break, though, so they've been here all day. For their teacher, Marie Solano, it's been a long one. "They watched movies in the morning, and now they're rambunctious," she explains. Most of them won't be going home for another three hours.
When the play-fighting ends, Demetrey turns his attention toward two toys. "Kill him, kill him, kill him!" he shouts, as he slams Pikachu against a stuffed animal. When he tires of bashing the toys together, he approaches two boys who are playing quietly at a table and grabs a toy out of one of the kid's hands. The boy demands it back, but Demetrey has his arm poised behind him, ready to throw it. When Solano tells Demetrey to return it, he flings the toy across the room. Solano tells him to get it. He doesn't.
The only girl in class, a quiet six-year-old with fingernails painted green for Saint Patrick's Day, looks up from the picture she's drawing to survey her classmates. The expression on her face says she thinks they're from another planet.
Demetrey picks up a cushion and hurls it on top of the table where the two boys are sitting. They join Demetrey in pushing the cushion to the floor, where they hide under it. After a few minutes, they emerge, wrestling. The little girl rolls her eyes and rotates her finger beside her head, indicating that she thinks the boys are crazy.
The boys call each other "butthead" and then giggle at their transgression. But the playful rough and tumble turns violent when Demetrey socks one of the boys in the eye. At that, Solano orders Demetrey to take a seat. He screams and cries in protest, claiming that the other boy hit his friend.
"I didn't do it, I didn't do it," he screeches, his voice choking on his sobs.
Solano tells him for the second time to sit down at the table. It's snack time, and there's a special treat today: A cake with green icing in the shape of a shamrock. The little girl helps Solano wheel the cake in from the kitchen and set the table. Demetrey is still sitting in the middle of the room bawling and yelling. "Demetrey, one last time: Put your shoes on, wash your hands and sit at the table," Solano says sternly.
Demetrey ignores her. Two of the other boys chase each other around the room, also indifferent to the teacher's instructions. Solano's frustration is clear. She asks one of the boys if he's taken his pill yet; he has attention deficit disorder, and he's wired. He claims he took his medication earlier in the day.
After a few minutes, the boys settle down and take their seats. Demetrey has stopped crying and seems to take an interest in the cake, realizing for the first time that it's there.
A few minutes later, daycare director Joyce Kinney walks into the classroom; it appears that the boy with ADD did not tell the truth about taking his Ritalin. Kinney has the pill in her hand, and when she tries to give it to him, he refuses.
"How many people think he should take his pill?" Kinney asks the children. They all raise their hands.
"Maybe if we don't look at him, he'll take it," one boy suggests.
The kids cover their eyes. But the boy keeps his lips closed tight, as if to prevent the pill from being forced into his mouth.
"How about we give you a dollar?" Demetrey offers. The boy momentarily perks up at that, but then shakes his head no as Kinney approaches him. Another boy encourages him to take his pill now so that he won't have to later.
"I'm only going to stay another minute and then I'm leaving," Kinney warns.
"Okay," the boy says matter-of-factly. He stares down at the table, his arms crossed.
After a couple of minutes pass in silence, Kinney leaves, defeated.
Aggression and defiance are commonplace at the Renaissance Children's Center. Originally a part of a Colorado Coalition for the Homeless program called the Family Community Center, the daycare has been open for six years. During the first four of these, the Family Community Center was located in the coalition's building in downtown Denver; it was a place where homeless women could study for their general equivalency degree, take parenting classes, receive daycare for their children and get mental and physical health care.
Although funding for the Family Community Center eventually ran out, the daycare stayed open, and in 1999, it changed its name and moved to Lakewood, where the coalition was building apartments for low-income families, some of whom used to be homeless. "We convinced them that we were providing a valuable service, so they agreed to give us this land," says Cathy Danuser, the center's family-services coordinator. The Renaissance Children's Center is now available to kids living in the coalition-owned apartments, as well as those in the surrounding neighborhood.
Many of the approximately 98 children who are enrolled at the center, at 1797 Kendall Street, have either witnessed domestic violence or been abused themselves, Danuser says. A lot of the kids, who range in age from six weeks to twelve years, have never known stability -- they've either moved frequently, been homeless, or both. At least half have emotional problems, and about 10 percent have severe mental health problems.
That's why therapists from the Mental Health Association of Colorado (MHA) Pro Bono Mental Health Program have been working with kids at the daycare since it opened, trying to teach them empathy and conflict resolution. The MHA is a nonprofit organization that refers mentally ill people to various agencies for treatment, tries to influence mental health legislation and pairs therapists with homeless shelters, community centers, schools and safehouses.
Julie Underhill Butscher, who directs the program for the MHA, says that providing mental health services in daycare centers makes sense because it's a familiar environment for kids. "We want to make getting therapy easy," she says. "When you're working with kids who already feel safe in their child-care setting, they're more willing to talk to adults. All parents have to do is sign a release saying it's okay for their kids to see the therapist at the center. They don't have to worry about transportation or about pulling their child out for treatment.
"For most people, if they have an excuse not to get therapy, they don't," she adds. "We often find that parents have some of the same mental health issues as their children. If someone had worked with that parent, their kids might not have developed the same problems."
For the last two years, Ann Prosser, a licensed child, adolescent and adult psychologist in private practice, has been spending about eight hours a week at the Renaissance Children's Center, where she provides group and individual therapy for children and helps parents learn how to handle their kids' behavioral problems.
Prosser, who is assisted by a doctoral student in psychology at the University of Denver, gives kids tips on what to do when they're angry or frustrated: Rather than hit another child or destroy property, she tells them to take deep breaths, to spend time alone or to do something they enjoy to get their mind off their anger. Prosser has also given parents tips on how to stop their kids from bullying and has held classes in which she's taught kids -- some of whom have been sexually abused -- the difference between appropriate and inappropriate touching.
"The more we can serve kids at an early age, the more likely we are to stop the cycle of abuse. If kids can learn empathy for others and learn ways to express anger, they may not react so violently later," she says.
Prosser also teaches teachers how to manage children with behavioral problems -- something that could be very helpful to an industry that already has serious difficulties retaining employees.
Mental health professionals, educators and politicians are now beginning to realize that the MHA's approach -- providing services for children in daycare, where behavioral problems first appear -- could be a way to help prevent kids from growing into a life of unemployment, psychiatric hospitalization, homelessness or crime.
There is already evidence that many juveniles who commit crimes have a history of mental illness; a 1997 Colorado Department of Youth Corrections study, for instance, found that 24 percent of juveniles in detention in this state have severe to extreme mental health problems and that 65 percent suffer from moderate mental health problems.
The state government, as a result, has become increasingly focused on early intervention. For the last four years, the legislature has funded two pilot programs, one in Denver and one in Boulder, that, like the MHA's pro bono service, pair therapists with daycare centers. In January, the Colorado Department of Human Services awarded grants to fund eight similar programs. In the future, the department would like to see therapists working with all 7,000 daycare providers in Colorado.
That would be wonderful for the students, as well as for the people who work in daycare, says Solano. She started teaching at the Renaissance Children's Center in February. "There are things I think I can handle and things I'm not sure I'm handling right," she says, "so I've gone to the therapists with certain situations."
Demetrey, in particular, has been a handful. "He's really impulsive, and he's destructive to toys in class," says Danuser. "He fires up really fast, but it takes a long time for him to calm down. You never know what will set him off."
"A lot of parents have been complaining about Demetrey," says his mother, Tiffany Martin, who suffers from her own mental illnesses, including depression and anxiety. "I've had to pick him up once from school and once from daycare because he was so out of control. I couldn't believe he was my son. He got into a fight with another boy at daycare, and when the teacher asked him to find something else to do, like color a picture, he said, 'No, I don't want to.' He's been really difficult. I've even taken away his Game Boy and his scooter, but it hasn't helped. We're at a standstill."
Martin says Demetrey's two older brothers also had problems in daycare. But with Prosser's help, their behavior has improved dramatically. She plans to meet with the child-care providers at Renaissance to come up with a plan to help Demetrey as well.
In January, U. S. Surgeon General David Satcher issued a report on children's mental health in which he said that "the burden of suffering by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral and developmental needs are not being met by the very institutions and systems that were created to take care of them."
Satcher went on to report that one in ten children in this country suffer from mental illness and that only half receive treatment. The statistics in Colorado aren't much better. Of the more than one million kids under the age of eighteen, 8 percent, or approximately 86,460 kids, have mental health problems, according to the state's Division of Mental Health Services; of those, 60 percent, or 51,876 children, are not getting treatment.
The reasons for this are legion, but many mental health professionals and parents attribute the scarcity of help primarily to a dearth of child psychologists and psychiatrists, to a lack of public understanding about children's mental health needs, and to the difficulty in getting HMOs to cover mental health treatment.
"I think one of the reasons this hasn't surfaced as an important issue in the mental health community is that parents don't want to admit that their child is out of hand," says Oxana Golden, director of the child-care division of the Colorado Department of Human Services. "It's difficult for parents to think that something may be wrong with their child."
The fact that adolescents and adults are already on waiting lists for treatment makes it even harder to focus on the needs of young kids, Golden explains. "The whole mental health system is underfunded to begin with. It's so hard just to keep up with the needs in front of us that it's difficult to think beyond that. We don't have too many professionals on the mental health side or on the early childhood education side who are trained to deal with problem kids. And most mental health centers don't work with kids under school age."
Even though research points to the first three years of life as being the most critical in a child's development, the mental health needs of young kids are still confounding. The reason for that is simple: Before kids can talk, it's hard to know what's really going on with them. It's also hard to distinguish the "terrible twos" from something more serious, such as an underlying mental illness, says Golden. Even when kids are old enough to talk, they usually don't understand -- or can't express -- the cause of their behavior, so they typically aren't diagnosed with a mental illness until they're much older.
But the warning signs often appear early. "I hear over and over from child-care providers that they know at age two or three if a kid is going to be bound for juvenile justice," Golden says.
To address the problem, in 1997 the Colorado Department of Human Services created the Early Intervention Program for Young Children. The program's mission was to get therapists from mental health centers in Denver and Boulder to go into daycare facilities that serve mostly low-income families and help kids with behavioral problems. The state legislature agreed to fund the two pilot programs at a cost of more than $350,000 a year.
As a condition of receiving the money, the human services department was required to show how treating children with behavioral problems early on would save the state money in the long run. In its report, which was presented to the legislature last fall, the department provided several scenarios involving children who, were it not for early intervention, would be prime candidates for psychiatric hospitalization, foster care, special education or juvenile detention.
One of the examples was that of Abraham, a child in one of the two pilot programs, whose name was changed to protect his identity. "Abraham seemed angry and sad," the report reads. "Although very bright and verbal, he was impulsive and immature. Change was difficult for him, and he had temper tantrums at many points during the day. His teachers isolated him from the group when he had emotional outbursts, and the other children avoided him. He clung to his mother, Betty, when she brought him to childcare and kept telling her he didn't like it there. Abraham's father was terminally ill, but no one had discussed the situation with Abraham.
"Children with emotional and behavioral problems can experience negative relationships with peers and childcare providers," the report continues. "These children are at risk of school failure even if they have above average intelligence. Early intervention helped Abraham and his family. If Abraham continued his negative feelings and problem behaviors into public school, he would be a likely candidate for special education. One child diverted from special education would off-set the cost of five children by the Early Intervention Program."
The department concluded its cost-savings analysis by noting, "There is no way to predict the life course of these young children, but $390,212 would be offset if just: Eleven children avoided one year in special education; ten children avoided the average six-month stay in foster care; four children avoided the average 63-day stay in a psychiatric hospital; two children avoided the average 15.6-month commitment for delinquency; and one family avoided TANF (Temporary Assistance for Needy Families) for the average twenty months."
Mary Grimmer, program manager of early childhood services at the Mental Health Corporation of Denver, the nonprofit that runs the Denver pilot program (it's called the PEARL Project, or Parent Empowerment Alternatives with Resources and Learning), has already noticed a change. "We've definitely seen kids showing less behavioral problems in class. Kids haven't had to leave the centers as much, and teachers are feeling better equipped to handle problems; they feel more supported and less helpless now," Grimmer says.
The MHCD has assembled a six-person team of clinicians and early-childhood specialists to go into fifteen daycare centers in Denver. Team members hold classes in social skills, anger management and anti-violence for the kids. They also offer family, group and one-on-one play therapy, and they train teachers how to handle disruptive children and to recognize signs of abuse and emotional trauma. The PEARL Project has served more than 1,300 kids this year.
The structure of Boulder's pilot program, dubbed the Child Development Program, is almost identical to that of Denver's. The Mental Health Center of Boulder County regularly sends four clinicians from its Children and Family Services Team into seven daycare centers, where they work with about 400 kids a year on developing social skills, anger management, impulse control and empathy. The clinicians also work with families on parenting skills and improving communication with their kids.
"People tend not to think about mental health until there's a diagnosed mental illness," says Pat Carruth, coordinator for the Child Development Program. "And yet we don't think of nutrition only when a kid is starving. Kids' mental health should be just as much of a concern as their physical health and cognitive development." And children are only becoming more aggressive, she adds.
Janae Weinhold, a licensed professional counselor, children's mental health consultant and attachment-disorder specialist, has some ideas about why kids have been getting more aggressive in recent years. "There's no one cause; it's a systemic problem," she explains. "Young kids are being exposed to more stress now than in any time in history. More and more, both parents are working and spending less time with their kids. Kids are being expected to become independent faster. And children are going into daycare earlier and staying there longer. Some kids are in daycare for ten to twelve hours a day. I like to call ADD adult deficit disorder: Kids aren't spending enough time with their primary caregivers."
Weinhold's theory was supported last month when the National Institutes of Health released the results of a ten-year, ten-city study on daycare. The study found that the more time kids spend in daycare, the more likely they are to exhibit behavioral problems; in fact, children who spend more than thirty hours a week in daycare are three times as likely to be defiant, aggressive and disobedient than those who spend less than ten hours a week there.
There are approximately 165,000 kids enrolled in some 1,800 daycare centers and with 5,200 in-home daycare providers in Colorado, according to the Colorado Office of Resource and Referral Agencies (CORRA). And because daycare has become a way of life for so many families, the high employee turnover rate is a critical problem, Weinhold says. "When young kids are exposed to so many different caregivers, it becomes difficult for them to attach. Every time a new caregiver comes in, they attach, and when that person leaves, they detach," she says.
The turnover rate for employees of daycare centers in Colorado ranges, on average, from 27 to 40 percent, according to a recent CORRA study. Child-care workers leave because of the low pay (a teacher with three to ten years of experience earns an average of just $18,000 a year), but also because they get tired of being disciplinarians.
"In our first year and a half, we had an 85 percent turnover," says the Renaissance Center's Danuser. "Every two to three weeks, we were replacing someone. It has slowed down since then, but we're still losing a staff member every three to four weeks. A lot of the teachers don't know what they're getting into. They don't realize the behavioral problems there'll be and how those will affect their ability to teach."
And since it's so hard for daycare centers to attract and keep employees, daycare directors often choose to expel difficult kids rather than risk losing employees, says Deb Lawrence, executive director of Child Care Connection, a child-care resource and referral agency serving El Paso, Teller and Elbert counties.
"Some kids have been kicked out of daycare four or five times before they're four or five years old," she says. "Some kids are being kicked out of up to ten child-care programs."
Last fall, the state human services department and the Center for Human Investment Policy (CHIP) sent surveys to 6,000 licensed child-care providers to determine the severity of mental health problems in daycare. The more than 1,000 daycare centers that responded serve about 26,000 kids in an average month; they reported that 1,466 children had left daycare in the previous year because of emotional or behavioral problems.
As for their caretakers, the study reported, "Respondents cite high levels of stress, feeling frustrated, feeling exhausted, and feeling challenged as the major impact of working with children with emotional or behavioral problems. Some teachers say they feel 'inadequate' or 'tired,' or they see themselves as 'a failure' or 'out of control.'"
CHIP researchers also visited many of the daycare centers where they'd heard "stories of toddlers being 'expelled' from every licensed child-care center and family child-care home in the community due to uncontrollable temper tantrums. They were hearing from early-childhood teachers about preschoolers who had raged through the classroom causing thousands of dollars of damage and causing adults to seek medical attention for injuries sustained trying to contain these youngsters. Other teachers were relating stories of depressed toddlers and increasing numbers of two- to five-year-olds being prescribed stimulant drugs to control hyperactivity and inattention....CHIP found that 84 percent of respondents put mental health, as evidenced by emotional or behavioral problems, at the very top of their list of concerns for young children."
These findings confirmed what state human services officials had already been hearing from daycare providers, and even before they got the results back, they decided to use money from their own budget to bring mental health services into more daycare programs. In January the office doled out $80,000 in grants for eight programs serving daycare centers in a number of counties.
The human services department's Golden is happy to see such programs in more daycare centers, but she says that $10,000 per program is hardly enough to provide the kind of therapy that's really needed.
El Paso is the only county in the group that started providing mental health services before the state stepped in to help; the Child Care Response Team, which is run by Lawrence and has been in existence since September 1999, consists of seven mental health specialists, child behaviorists, social workers and occupational and speech therapists who work in more than eighty daycare centers. The $300,000 a year that's needed to run the program comes from several grants and donors; the extra $10,000 from the state will be used to provide therapy for 25 families. "If you do any kind of intervention with a child, it's much more successful if the whole family takes part," Lawrence explains.
When a daycare center requests help, a member of the response team goes in to observe the kids and to assess the problems; if a child shows signs of developmental delay or serious mental illness, the team members refer them to the right services. They also teach parents how to handle behavioral problems at home.
"The things we do are very simple. We help kids with communication and social skills. Often, child-care providers don't have the time to do that, so having an extra person in the classroom really helps," Lawrence says. So far this year, the response team has worked with a total of 1,700 kids -- 194 of whom needed intense help. "The child-care centers get one to four hours a week of direct coaching with the teacher and the children. It usually lasts three to six months, and then we're done. Teachers can do the rest from there; we just give them better observation skills. They can prevent problems from escalating just by being keyed into the kids' body language."
The state Department of Human Services will report to the legislature on the effectiveness of the ten pilot programs in February 2002 and on what it will take to expand mental health services to every daycare program in the state.
At the same time, a newly formed committee called the Statewide Initiative for Children's Mental Health will be researching how Colorado can develop a statewide plan for providing mental health care to young kids. The fifty-member committee, which is made up of mental health and early-childhood-education professionals, as well as people from the state human services and education departments, began meeting in February; its members hope to spend the next year researching children's mental health programs in other states including Florida, Arizona and Ohio, where such plans are currently being developed. They'll also come up with ways to fund the Colorado plan.
"We can't just rely on the state to fund it," says the Mental Health Corporation of Denver's Grimmer, who is a member of the committee.
Weinhold, who is also on the committee, says the initiative has been many years in the making. But after the Columbine High School massacre two years ago, they got serious. "Columbine really galvanized us, and it was really a catalyzing event around the country. The Columbine shootings may not have happened if there had been early intervention for those boys."
The committee members and officials at the human services department hope that the public and the government will start taking children's mental health more seriously.
"I would like to see a trained professional workforce that has the ability to deal with mental health problems, early childhood development, developmental disabilities and substance abuse, because they're all interrelated," says Golden. "Ideally, I would like to see every child-care provider in Colorado hooked up with a mental health consultant."
Tiffany Martin wishes every parent could get the same kind of help that she and her children have received at the Renaissance Children's Center. The 29-year-old, who works as a clerk at Denver Health Medical Center, knows what it's like to have a mental illness: She has had panic attacks since the age of ten, but they didn't impair her life until a few years ago.
For no apparent reason, Martin sank into a deep depression at that time and was afraid to leave her house. She managed to see a doctor who diagnosed her with severe depression, anxiety disorder and agoraphobia, but she eventually became so frightened to go outside that she had to quit her job. She couldn't even get food stamps, because she was terrified to go to the Golden office to apply. Martin stayed in her home for a year.
Luckily, she was referred to a therapist who made home visits. "She was my crutch," Martin says. "The commitment she gave to me and my family was unbelievable. Two or three times a week, she'd come to my home. I had lost a lot of weight, and she'd make sure I was eating. She sent me cards and gave me the boost I needed to get myself better."
In 1997, Martin resolved to leave her house. She decided her first trip would be to a safe place: her mother's house. "One day I got in my car and drove there. It was really hard. I was really shaky and nervous, and I worked on my breathing the whole way there. When I got to my mom's house, she opened the door and started crying," she says.
Since then, Martin has been working, little by little, to stray farther from her home in Lakewood. She's working at the hospital again, but she can't go as far as Aurora or even Englewood. "My kids want to go fishing and camping, but I can't. I haven't been to the mountains since I was sixteen. I don't even remember the mountains. I can't go on vacation. My husband went to Miami at the end of March, and I couldn't go. I know it's been really hard on him and my kids."
Now she's seeing the signs of anxiety disorder in the oldest of her six children, eleven-year-old Ryan. He had his first panic attack at the age of four. "I knew it was a panic attack because he said he couldn't breathe," Martin says.
Ryan is also claustrophobic, so when he was in a previous daycare center, Martin warned his teachers that he couldn't go to cramped, contained places such as movie theaters. But three years ago, his class went to an IMAX movie at the Denver Museum of Nature and Science. When Ryan protested outside, his teachers dragged him in anyway. "He freaked out, and they called me and said he was misbehaving," Martin says.
A year later, Martin moved from her home in Denver to an apartment across the street from the Renaissance Children's Center, where she eventually enrolled Ryan and her other children. He's had panic attacks at school and at home, but he hasn't had any in daycare. He has had behavioral problems at Renaissance, however, and so has his ten-year-old brother, Michael. The two of them used to bully other kids. If they wanted something another child had, they'd take it. "A woman has come in to teach them techniques other than bullying," Martin says. "She's taught them that instead of grabbing something, they should calm down and ask the other children if they can play with them or if they can play with the toy after they're done. It's really worked. Now they wait for whatever they want or they offer to play with the other kids. At home they used to grab things, but now they ask permission."
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Martin attributes the changes in Ryan and Michael to the daycare center. "I don't think we'd be as far as we are if it weren't for the Renaissance Children's Center," she says. "At home there's only so much you can do."
Now she's waiting for Demetrey's problems to subside. "I think he feels different than my other kids. He's the only one of my kids whose father is black. He's also the middle kid, age-wise. He's a big attention-seeker. With six kids, it's hard to give just one child attention, so he seeks that attention at school and daycare. If the teacher is giving another kid attention, he'll act up," Martin says.
She believes every child in daycare should have access to therapists. "I think that even if parents feel their child doesn't need it, it's good for them to have someone else to talk to. I know that if I ever have to pull my kids out of here, it's something I'll look for in another daycare."