Health, Safety, and Mental Health

Ann Linehan: Good afternoon. This is Ann Linehan from the Office of Head Start, and we are so happy that you have joined us this afternoon. We have little over 1,200 folks in counting. This is the 5th of our 7 Webinar Series.

And I have to say, I asked to be part of this today because I have got a lot to learn about health and mental health. And this has been quite a journey for us at the Office of Head Start, rolling out the Head Start Standards. And I think every one of these sections have been exciting and today we expect the same.

Marco, I sent you some excitement. But before we begin with the formal presentation, why don't we turn it over to Beth? — All right, you want me to walk through the agenda. I am sorry, I didn't see this. Go ahead. I got my coach here. So, we are going to talk about hot topics and then we will then shift to the monthly focus: Health, Safety and Mental Health. And then we'll take a look at some recent resources and then we'll do a wrap-up. So why don't we now shift to the hot topics.

Colleen Rathgeb: Sure, I this is Colleen Rathgeb and I am happy to be with everybody today. So, Beth and I, we are going to talk a little bit through a couple of sets of things we are hearing about and generally things with the questions that we are receiving in the response process. So, the first thing we just want to make sure everybody has seen what the PI that came out last month and with the attached Frequently Asked Questions around background checks. So, hopefully everybody is familiar with that now.

Remember that we extended the effective date for the new background check revision until next September of 2017, the end of next September so that it aligns with the child care requirements, so folks know that because of changes in the CCDF, Law and Regulation all states are setting up processes to be able to do complete background check requirements for all child care providers. Folks that are licensed to get child care and/or for entities like Head Start programs that are eligible for child care. So, some of the things we wanted just to highlight is again, we pushed up that effective date so that as dates for setting up this system.

Head Start programs and the state can be looped into that process. We also made it clear that the provisions around contractors are not as broad as some people were concerned that they were, that we are really focused on contractors that interact by services to children and families or could have access to children, so, there is not out auditors that never come on site or delivery that comes to the kitchen and never be access into the facility. Those are some of the big questions that we are getting that we wanted to clarify.

Also clarify that if a state does a background check and provide the Head Start program with the information that this person need one of the state disqualifier or not, that is sufficient. The Head Start program does not actually have to review the specific information about the individual criminal history or lack thereof, but if they were red light or green light from the state is sufficient.

So we encourage folks to read the ACI if you haven't. Look at those FAQs, and so unlike some of the questions where we are just doing individual responses that to folks that are requesting clarification these were the ones that we have broadly saw that they were confusion in the field and that we needed to put out very detailed specific policy responses, so people were broadly assured of how we would be interpreting these Standards.

The other hot topic that I just want to also mention because we have gotten a number of questions about this and we have been a little surprised but we have gotten questions about the program's ability to enroll 3-year-old. if they transition 3-year-old sometimes during the year. So if they transition after the state what their cut off would be to enroll in kindergarten, we have not changed that provision, we did not change that provision when we left put out the eligibility reg. but we think there is a lot of either not understanding how to read it or some concerns about that. So if you look at the Standards in the eligibility section, so obviously there has been a little bit of wait for my Standards for some time.

I hope people in the phone are jumping in. If you are looking at 1302.12, So, Subpart A of 1302, we really

— you look at the age eligibility section, which says very clearly that the child is 3 or is 3 by the kindergarten cut off, So it's 1302.12 (b), and so again it says, for Head Start — for Early Head Start you have to be an infant or a toddler or younger than 3 years old and then for Head Start you must be 3 or turn 3 by the date used to determine eligibility, so that is allowing children that are not yet 3 to be enrolled in Head Start.

if they would have turn 3 by the time even October 1 or a date that is later in the year so but it's so very silly to say that they could be 3 or turn 3 so in all cases, a child by based on our eligibility requirements, a child that is 3 is eligible to enroll in Head Start.

We know some programs make — have their policy that they want to first enroll children that will only be one year from kindergarten or two years from kindergarten. and so we know that in some cases that 3-year-old could be there longer, but there is not nor hasn't been a prohibition on enrolling a child in Head Start when they turn 3.

So, this is have gotten more questions that we expected in this area, we know this, again, maybe the program to think slightly differently, but we were very clear that we have the eligibility, once a child is 3, by the federal regulation they are eligible, they do not necessarily be selected or get the highest on your list but they would be eligible to be enrolled in Head Start. Those are the two big topics that we wanted to just really cover today.

And now I am going to turn over to Beth to talk a little bit about how the questions on processes going that we have been working on in some of the areas where we are seeing more questions.

Beth Meloy: Yes, so we just wanted to remind folks that we do have a Central Office of Question and Response Process. Questions can be submitted from grantees directly through the ECLKC Contac Us button, and we received those questions here at Central Office and work with our subject matter expertise and leadership here to provide individual responses to every single question. So if you submit a question, then we are committing to sending you a response to that question. We have been able to respond to more than half of the submitted questions so far, and we have several questions that we are working on, responding to now. There are some questions, and this is part of the reason that we set up this process.

There are some questions that are coming that have high priority for us and need for some broader guidance, and those are questions we are setting up a process to really work through and produce either tip sheets or whatever like guidance made look like or some kind of policy clarification, if it is needed to really help clarify areas of confusion. So, a couple of those areas are things like the Quality Rating Improvement System, the QRIS, and what will really be determining whether or not the requirement for participating in QRIS kicks in for a particular grantee in a particular state.

We have also gotten general questions around — that are highlighted the need for a little bit more of specificity around curricula and certain staff qualification. So that is just to highlight that if you have sent in a question related to that, you may have a slightly longer wait frame, and we might be sending something that more like an interim response to you to let you know that we are working on giving broader guidance, which we plan to share publically. So that guidance will be similar in terms of the ethic used that we decided to publish for background check.

We saw high volume of questions related to several themes of topics and we decided that we wanted to put out publically some clarification instead of continuing put those back to individual through the process, although if you were to ask a question about them, we will still respond you, It's the same part of process that we are going through with these other questions.

So we just wanted to highlight for folks that we have heard those, that we encourage you to continue submitting those questions because that really has helped the process that we have in place for identifying areas that you need additional clarification. So, even if you think someone else may have already addressed the question you have, we encourage you to submit it through the ECLKC, so we have a sense of what the questions are and sort of the volume of confusion about a particular topic.

Ann: I think that a lot of the questions that you have answered individually that the Office of Head Start answers, in many ways is reflecting the confusion about the previous regulation, so I think this is revealing. The fact that we have got this process is helping us understand what people were confused even prior to the new Head Start Performance Standards

Beth: Yes, that's actually right. This 3-year-old issue is a great example of that where nothing has really changed in our Standards, but because people were directed to really dig into the Standards perhaps they are easy to read and understand that's highlighting questions about beliefs that were held in terms of what and wasn't required by Head Start, and some requests for clarity about really what is the requirement. So Marco, I hand it over to you and Sangeeta.

Marco Beltran: Great. Thank you. I just wanted to start off first by thanking Head Start as a community that make my job very easy to do and I love my job for the fact that I get to talk about all the very positive staff that we do in Head Start, and I think health is one of those areas where we do an incredible amount of work, a phenomenal job. It's nice to talk to associations and researchers and all these people that have questions about health services, where I get to talk about the high number of kids were immunized in our program, and I get to talk about the high number of kids who have continued accessible care.

And a lot of that is attributed to the work that Head Start does, so I thank you for that. And I love my job for that reason. So what we are going to be covering is, what we are going to be covering all the sections in the Performance Standards. And what we are going to do throughout the presentation is as we cover the section and if any question has come through that we were able to answer, we'll provide that question in the slide and then give you an answer to that question.

So to start off as it relates to Health Program Services. What did we do? So we updated, we reorganized, and streamlined the requirements in order to make them easier to find, follow, and implement. From the previous Standards, we moved the sections related to education and developmental screening and assessment into to the Education and Child Development Program Services.

We also moved language regarding individual stations of services into the additional services per children with disabilities and the Education and Child Development Program Services. The entire Program Services Subpart was reorganized for the sake of transparency, clarity and improved implementation.

So, why did we make these changes? We made them because the previous Early Childhood Development and Health Services Subpart confused users and did not clearly delineate services or outlined the chronological steps programs are required to take to deliver those services. To remedy this confusion, we restructured the Early Childhood Development and Health Services Subpart to clearly delineate the steps that will ensure that programs deliver services that promote the overall health of all children.

We rechanged and streamlined a majority of the policy requirements in the new Standards. Specifically, we rechanged the core Health Services including hearing and vision screening, ongoing care, and follow- up care, as required by the Act. And we rechanged these requirements both because the Act clearly links health, mental health, and nutritional services to the purpose of Head Start and because of research has demonstrated a strong link between child, health, school readiness, and long-term outcomes. The most substantial changes are in the Child Health Status and Care Section, the Child Mental Health and Social Emotional Well-being, Family Support Services for Health, Nutrition, and Mental Health, and Safety Practices.

We have several important additions, specifically, we highlight Oral Health, our small but mighty section and Parent Education and Health more explicitly by creating new sections that outline requirements in each of these areas. Also, we strengthen provisions to better reflect best practice and to ensure that mental health services are used to improve classroom management and to effectively address challenging behaviors when they arrived.

Sangeeta Parikshak: Hi everyone, this is Sangeeta. I am going to be interjecting throughout to talk about mental health as well. So, as you may have noticed in the new Standards, we have a variety of sections that touch upon mental health and social and emotional well-being. And I thought it might be helpful for everyone to get a sense of where we are coming from. Why is that we made the changed that we did and what were our goals and having you implement some of these new Standards.

So as many of you probably know I'm working with folks in the program both staff and parents and children. There are often times a lot of confusion around what mental health really means and there is sometimes some stigma attached to mental health. So, part of some the changes that we have made in the regulations is to really help programs in creating a culture that promote positive mental health and social emotional well-being, reduces the prejudices and discrimination around mental health services, and one of the ways that we do that is really improving parents and staff understanding of what mental health means for children as well adults.

And you see in some of the wording changes that I'll talk about later how we try to do that. We also hope that in implementing some of these new Standards we can empower programs to know how to handle challenging behaviors. We often hear from folks in the program that there is a lot of concern around some of the difficult behaviors that arrive in classrooms and we really want to support staff around improving classroom management.

One of the main section that have gotten a lot of attention and it was a big kind of change in the new Standards is the 1302.17, which focuses on suspension and expulsion. But I really want people to understand that we have done is codify long-standing practice to not expel children from Head Start program. This is not a new practice, we actually feel like Head Start has been a leader in this field and we wanted to put it in the Standards in black and white, so that other folks who are looking to improve practices around working with young children can see that we are putting our stand down saying that it's really important that we not expel children from the program.

So, what's this section that is that it prohibits expulsion and severely limits suspension, and the focus is really on how is that we can keep children in the program particularly if they are having challenging behaviors and not send them elsewhere. We have specifically stated that if a child qualifies for IDEA or 504 Plan they cannot be excluded from the program.

And, we have provided steps for programs related to challenging behaviors. So we outlined what the program must do to determine if a temporary suspension is necessary, how to return to full participation of all program activities as quickly as possible. So this includes things such as, documenting the action and support needed, providing home visits, determining whether it's appropriate to refer a child to a local agency responsible to implementing IDEA.

So these are some of the steps that we have outlined. I also want to emphasize that the rule does allow for some flexibility, and that if a program has explored all possible steps and outlined and documented all steps taken, and this has determined that the program is not the most appropriate placement, the program must directly facilitate the transition of the child to a more appropriate placement. We don't want the child to be kind of in limbo at any point.

We want kind of warm hand off, what we call it in the health world, from one placement to another. This section also elaborates on engaging mental health consultants, which I will describe a little bit later on when we talk about 1302.45. And I just want to address one of the questions that we have been getting around this section. The question is, “can a child be removed from center based services? and put in home service due to behaviors problems?"

So I would like to direct you all to section 1302.17(a) 4, 3, 5, which require to different programs allow a very limited use of temporary suspension due to a child's behavior, So programs must provide services that include home visits. And so changing a family program option from center-based to home-based because of a child behavior will not be acceptable based on this regulation.

And also if you think about kind of the purpose of the home-based option is usually made at the time of the child's enrollment, it's with a mutual agreement of the program and the parent, and it's really selected as an option because that meet with the family's need. Generally including that a parent is at home with the child and wants to role child's teacher.

So it's really not set up as a way to kind of put a child back in the home if they are having challenging behaviors, because if you think about it, the behaviors are probably happening at home as well as in the classroom and what we really need is to best support the parents as well as the staff, and everyone

involved to figure it out what's going on and how we can really promote the child's social and emotional growth.

Ann: Sangeeta, someone asked a question when you, as you were talking. It seems like this is askable to preschoolers, but is this requirement covering birth to 5, both Early Head Start and Head Start?

Sangeeta: It is, it is covering birth to 5, I mean typically I think, probably one of the reasons for that question is that, when we think in challenging behaviors, we think about children that are a little bit older, but we have heard some isolated incidents of sometimes the child is a baby, it's probably crying a lot. The staff doesn't know how to calm it down, the parents don't know how to calm it down, and they think, “Well, this isn't the most appropriate placement. We are going to send them back home.” The parent feel like, “Okay, I am not supported now.” So, I think in those instances, this definitely covers those types of occurrences.

Marco: We didn't want you throw you for a loop by having a conversation on suspension and expulsion, but we thought that every time we talked about the mental health, the implementation. These are related to the Mental Health Standards, these questions always popped up so we just kind of wanted to get them at the very beginning. As we moved into the slide on the purpose. I see that were on the slide afterwards but I'll just describe the purpose slide, so we don't have to move backwards. The purpose, this particular section, the whole Program Services Subpart D now it continues the Purpose Section that did not exist before.

And we took the opportunity to identify or to describe our statement. Our statement in the purpose section is explicitly states the goal of the subpart, which is to ensure that program provides high quality health, mental health, and nutrition services and the purpose of such services is to support school, is to support each child's goal for school readiness. One of the particular things I'd like to point out when I am talking about the purpose section is that this is a section that we now find the reference to the Health Services Advisory Committee.

As we go to the collaboration and communication with parents, we believe communication and collaboration with Head Start parents, is fundamental to the delivery of all Head Start health services. The reason we placed the section at the forefront of the Subpart is because we want to better communicate, it's important to programs and to the public. The requirements for the program to communicate and collaborate with parents with regards to the children's health is written to reflect the applicability and importance of parental communication, collaboration, permission, and input for services described throughout the entire health Subpart.

Key concepts in this sections existed in the previous Standards and I know that we wanted to indicate that 1302.41 (d)2 is new and require programs to share policies for health emergencies that require rapid response or immediate medical attention. 1302.41 is kind of — it's my hefty Standard. It's the Child Health Status and Care. This section includes requirements for programs to determine children source of care to support parents and ensuring children are up-to-date for preventive and primary medical and oral health care and to ensure — to support parents to ensure children receive ongoing necessary care. It also requires programs to determine if children have health insurance and support families in accessing health insurance if they do not exist.

So to get a little deeper, right? We felt that the previous 1304.20 did not make the required services or the chronological order of the steps within those services clear, meaning that it combined requirements related to extended follow-up and care with those of initial screening and ongoing care, so it was a little bit all jumble up. 1304.42 is designed — this new Standard is designed to clearly delineate the steps determining the child health status and needed care.

In paragraph (a) within 30 calendar days program must determine whether each child is having appropriate source on ongoing care and health insurance coverage, and if it's not assist parents in accepting each. In paragraph (b), within 90 days, programs must determine whether children are up-to- date on scheduled immunization and well-child care, and if not assist parent in getting up-to-date or if necessary directly facilitate the provision of each services per children with parental consent.

OHS believe that the requirements for the program to directly facilitate health services if necessary is essential to ensuring all children are up-to-date specially with critical important vaccination. Under paragraph (b)(2), programs must ensure children are screened per health problems including visual and auditory concerns. Finally, in paragraph (c)(2), programs must monitor the implementation of follow-up care and monitor children for new and reoccurring health problems.

Each of these four steps were required previously, but the individual roles as well as the order were difficult to decipher, so it was confusing a lot of people. The explicit inclusion of health insurance on paragraph (a), also codifies — the long-standing practice. So, linking families with health insurance is a critical step in helping link them with providers, but giving the increased availability of coverage, we think that being explicit on this requirement is important.

We maintained each of these steps because research has shown that children who participate in a consistent schedule, well-care and immunizations are more likely to stay health and engage in program activities, leaning to improve school readiness, hence school readiness with health. — So, what do we do that was different from the previous Standards? — I'll try to reorganize them, so that's the big question that we get — So we reduced the time frame for determining whether a child has an appropriate source of health care to 30 days.

We still get programs 90 days to assist parents in accessing such as accepting source of care and to ensure children are up-to-date with EPSDT. We do however specify that an appropriate source of ongoing care cannot operate primarily as an emergency room or urgent care facility, because research has shown that families who have an ongoing source of continuous care are more likely to attend well- child visits, know what to do when the child is sick, and sick appropriate care for illnesses or health concern. Because developmental screening is closely related to educational services, we moved developmental and behavioral screening to Subpart C, child screening and assessment, so that's where they are located.

And we retained the sensory screens and other health related diagnostic tests, including those related to nutritional status in this section, because these screenings and tests must be in included in high quality health service delivery. We also moved and revised the requirements that such screening be sensitive to each child's background. This was moved into Subpart C, largely, because we wanted to reflect that this is a core characteristic — of an appropriate screening or assessment.

So what it used to exist in the previous Early Child Development and Health Services Section, the piece about individual stations of programs, so that has been moved. So we don't have that that way anymore. And we decided to moved it into two different sections, the one on additional services for children with disabilities and the one on education and child development program services. The reason that we did this was because we determined that the health services are individualized already by nature so it didn’t really make any sense to kind of address it there as well.

And finally, we clarified the use of program fund for medical and oral health services as well as the provision on diapers and formula. I think this is one of the questions that we used to constantly get related to programs, if we were able use program funds for these particular purposes. So, we moved into the first question. It's really funny because I saved two questions on the screen. There is actually look like more than two questions. — So I grouped our vaccination questions that we received.

They relate to kind of programs and enrollment for children that do not have health insurance. I mean [Laughter] did not have his/her vaccines And they are asking for one of the Standards this information is found. So, one of the things that we want to kind of address, and I think this answer, reflect both questions is that the Head Start Program Performance Standards differ to state requirements regarding immunization and differ to state requirements regarding immunization and enrollment.

The standard states that the program must comply with state immunization requirements and attendance requirements with the exception of homeless children. If the program determines that the child is eligible because they are homeless, the standard requires program to allow homeless children to attend without immunizations or other records for up to 90 days or as long as allowed under the state licensing requirements. I think that answer kind of applies to all these questions that you see on the screen.

Another question that we received is how often the dental exams and blood tests need to be updated as it relates to following current EPSDT requirements, and in this particular, the question that was proposed was saying that the requirement for the state was more rigid than the Performance Standards. So the Head Start programs relies on, everybody knows, — the state EPSDT requirements. So you if you are looking for information related to EPSDT, you can visit the ECLKC and search for EPSDT, and the first link that will pop up is title EPSDT by state. Now this is actually the most direct way to find that information.

Ann: Say that again.

Marco: So what you can do is to visit the ECLKC, and in the Search, type in EPSDT and the first link that will pop out is titled EPSDT by state. Click on that and then you'll have access to your EPSDT by state. So programs should develop appropriate schedules for children's medical and dental updates based on the state EPSDT requirements and any additional recommendations of the program's Health Advisory Committee. it's the way we would have answered that question.

Ann: I just want to acknowledge we have a lot of questions coming around the expulsion and suspension, and I think we are committed to answering those questions at a later date. I don't want people to think that we are ignoring them now, but I think we got to stick to what we can manage in this time slot.

Marco: Suspension and expulsion is a hot topic. Ann: Yes, it's — a lot of questions which is terrific.

Marco: So another question that we received is the fluoride question, facilitating fluoride question. I actually — the question that you see on the screen — I actually think it's two questions rather one question. In response to the question, they pulled out 1302.42, which is one of the Standards c(3), which indicates that programs must facilitate fluoride supplements. So the response to it is that the Standards reference in this question does not say "must provide" but says "must facilitate and monitor." Thus, programs are not required to directly provide fluoride supplement, but rather have a responsibility to facilitate access to fluoride supplements were necessary.

Well, the program is not required to directly provide fluoride supplements, they may choose to do so based on the recommendations of their Health Service Advisory Committee. The standard provides programs flexibility to determine the most appropriate way to meet the needs of the children and families being served based on the circumstances of their community. A grantee should use the relevant data, for example, in this case, information about availability of fluoride in the water supply, or health status of children enrolled in the program, and recommendations of the program's oral health professional to shape decisions about the level and type of preventive oral health measures and treatments necessary to meet the standard.

Programs should also consult the EPSDT Guidelines and the dental periodicity schedules for their state in order to understand any minimum requirements for the oral health care of the population being served by the program. So the second part of that question relates to the fluoride — using fluoride toothpaste and I just wanted to respond to that piece by just going directly to 1302.43, the Oral Health Practices.

This standard states that a program must promote effective oral health hygiene by ensuring all children with teeth are assisted by appropriate staff or volunteers if available in brushing their teeth with toothpaste containing fluoride once daily.

So, we are in fact say that that it is fluoride toothpaste. So to kind of further going to – dig into this little but mighty section a little deeper. In this section, we describe the oral hygiene requirements during program hours. The requirements in this section are not new. We simply moved and revised the previous Standards to more accurately reflect the expectations for hygiene practices upon which programs are monitored, namely ensuring children brush their teeth once during program hours.

While the previous standard specified that oral hygiene should be promoted in conjunction with meals, we removed this concept to give programs greater flexibility to determine how to best meet this requirement. Research has documented a link between oral health, and specifically dental pain, and children's attendance in preschool programs, as well as their ability to effectively engage in classroom activities, which is why we really kind of wanted to emphasize this standard by making it its own standard.

As it relates to child nutrition under section — Within the Act, — we have this piece that — established Performance Standards with respect to Nutritional Services. To implement this requirement as with other sections of this Subpart, we retained the majority of requirements of the previous standard in this section, although we reorganized them, right? to make them flow better. So we restructured the Child Nutrition Section to fully reflect nutritional services, programs provide directly to children.

So we moved and restructured the standards related to nutritional assessment and we incorporated into child health status, because we feel that nutritional status is an integral part of health status, so we wanted to keep them together, right? We also moved concept of family’s style meals to the Education

Subpart, because the concepts related to family style meals are meant to convey the importance of utilizing meal time as an opportunity for children to continue to learn.

Although we do still reference or we do identify family style meals in the nutrition piece, we moved — we directly linked them back to the standard that really identifies or describes what the concepts are. We also moved some provisions from the previous Standards on nutrition to Safety Practices. These are related to food sanitization, for example, and then also to the Standards of care, in which we — anything related to like food being used as punishment or reward. So, there are no longer in the Nutrition Section, like they use to exist.

And we just kind of thought that we needed to do that to kind of go to this idea of trying to clarify the Standards and make them easier to read. Also from the previous Standards, we moved the piece which requires programs to make accommodations for mothers who wish to breastfeed in the center, to this section, as it is directly related to the nutritional need of infants, and research has clearly established the benefits of breastfeeding. In addition, we added the provision for referring to a lactation consultant or counselor if needed. And finally, we also included a provision to make safe drinking water available to children during the program day.

Sangeeta: I am going to talk a little bit about the next couple of sections which touch again on mental health and social and emotional well-being. So this is 1302.45. You'll see here that we have added the terminology of social and emotional well-being. And the reason why we did this is thinking back to what I said earlier about the goals of some of the revisions. We are hoping if we do this that it'll start to change the discussion around what mental health is. Help people to understand that when we are talking about young children, we are talking about their social development and their emotional development, and hopefully this will help to move towards that goal of creating a culture that promote positive mental health. Also reducing stigma around mental health.

We are not talking about diagnosing children, but we are really talking about their development, which is linked to the Early Learning Outcomes Framework, which I know that many of you are familiar with. We have a whole domain on social and emotional well-being. And we are talking about that domain, we are also talking about mental health. Another thing that we did in this section is that we really wanted to improve how programs use mental health consultants. So we have — We hold a very clear list of how mental health consultation should be used. The role of the consultant is really to collaborate with everyone from the teacher, to the parents, to home visitors and all the other staff in the program. Also we talk about the utilization of consultants.

We say specifically that they should be utilized in schedule of sufficient and consistent frequency. We also have a new provision that we added around obtaining parental consent at enrollment or mental health consultation services. And we are really hoping — that says is that is helps to normalize mental health consultation services is that parent don't feel, "My child has a challenging behavior and that's why the mental health consultant has been called" but instead that when a child and parents are first coming into the program in enrolling that they are giving a packet of materials of services that are offered from the program and that one of them is mental health consultation services and there are available for all children and all families not just for isolated incidents.

And then linking back to what we were discussing earlier on suspension and expulsion. This is how we can link these two Standards, 1302.45 and 1302.17. Really what we are trying to do here is say that mental health consultants are integral to the steps outlined in eliminating expulsion and limiting suspension in the program. So, for example, we do talk about in the standard that before deciding if a temporary suspension is necessary, that we must collaborate with a mental health consultant, we must also collaborate with staff and parents.

Really get the whole team together to figure it out what is in the best interest of the child. We are really making this more of a prevention focus model, so if the mental health consultant is introduced into the family and child's life from enrollment, hopefully, we can start preventing some of those difficult behaviors from becoming a huge problem, figuring out what the child needs, helping to support everyone from the get go, and making it more a team effort.

We also talked about how the mental health consultant’s role is to really utilize community resources, so it's not about providing treatment, that is not the role of the mental health consultant, it's really, after careful discussion with everyone involved, it is determined that maybe the child will benefit from resources from some outside treatment. Then, it is the mental health consultant role to link that family to other resources, such as behavior coaches, psychologists and other specialists that will be beneficial to the child and family.

1302.46, Family support services for health, nutrition and mental health. So this section includes the requirements that address health, education, and support services that programs must deliver to all families. It consolidates requirements from the previous rule and improves the clarity and transparency of requirements. It also highlights the critical importance of parental heath literacy, which was not present before in the previous Standards.

This Section also clarifies topics that programs must offer for parents, so some of these include home health and safety practices, so this includes things such as the consequences of tobacco and lead exposure, healthy eating, so the negative consequences of sugar, sweets, and beverages is discussed here.

We also have breastfeeding support, so the lactation consultant would be an example of this section. And also parental and child mental health is another topic. So, when we talk about parental mental health, we pull out treatment options for parents as well as we specifically caught substance abuse problems, and we actually heard from the field that some of our latest research around the health manager descriptive study talks about some of the gaps in our treatment, our mental health treatment for parents, it's around substance abuse and how programs are really acting for this to be significant part of the program, so we have tried to put that in here.

And when we talk about child mental health in this section, what we are talking about is really helping parents to understand what we mean by appropriate social and emotional being and growth, and we are hoping that if we include this topic for parents it'll help empower them to determine what it's going on with their child in their home environment as well as in the program. We also talk about helping parents access health insurance for themselves and their families in this section and that's a new provision.

Marco: For Safety Practices. I think this is one of those sections that I think — When you hear people talk about the direction that we want to go with the Performance Standards and not being so prescriptive. I think this section, we really — you can really really see that from where it used to be in the past. So what we did with this section? So we moved all the provisions related to safety practices into one place.

We feel that basic health safety practices are essential to ensuring high quality care and propose strong safety practices and procedures that will ensure the health and safety of all children. So in some instances, we moved away from prescribing extensive detail when such level of regulation is unnecessary to maintain a high standard of safety and too inflexible to allow the growth in the standards safety practices.

One of the things that we kept on here was that programs were coming up with very unique and new ways of doing things but they were so prescribed from the previous Standards that they couldn't move into the new directions that they wanted to go to. So, this allows us for that flexibility and allows programs to adjust to their policies and procedures according to the most up-to-date information and things that happen locally and what's changing in their state versus what we are trying to do. In paragraph (a), we require that programs establish train staff on, implement and enforce health and safety practices that ensure children are safe at all times.

This places has a greater emphasis on ongoing administrative oversight and staff training regulations and should lead to better systems and practices when implemented. In paragraph (b), we require health and safety requirements for facilities, equipment and materials, background checks, staff safety training, safety practices staff must follow, hygiene practices, administrative safety procedures, and disaster preparedness plan.

The requirements are more informed by research and best practice. We require that programs develop and implement a system of management, training, ongoing oversight, correction, and continuous improvement, adequate to ensure child safety. In addition, we require that all facilities per center-based programs must meet life licensing requirements and all family child care programs be licensed to maintain in minimum level of safety. Finally, in paragraph (b), we require all programs to report any safety incident.

Additionally, safety practices related to background checks and standards of conduct including Head Start specific supervision requirements and provisions on seclusion and restrain, vaccination, and transportation are retained and strengthen in the appropriate Subparts throughout the Standards to ensure child safety. So there are other pieces where we also address safety practices as needed. So, to ensure programs are equipped with adequate instructions on how to keep all children safe at all times, we indicated that programs consult Caring for Our Children Basics and that's the way the PDF looks like on the screen.

We are trying to make it easy. One of the things that we have — Some of our programs are struggling with how to find it. It is on the ACF website and we are going to be putting it on or having a landing page on the ECLKC for programs to have an easier time to find Caring for Our Children Basics. So, what is Caring for Our Children Basics? It is set of recommendations, which are intended to create a common framework to align basic health and safety efforts across all early childhood settings. So there are not the minimum, right? They are just over considering the basics health and safety standards. I mean they are the minimum so we are just considering the basics health and safety standards, but they are not exhausted.

That was one of the things that we kept saying that just because you are meeting basics doesn't mean that's as far as you want to go. if there is a way for you to enhance your safety practices by all means we encourage that to happen. And there seems to be a lot of confusion between Caring for Our Children Basics and Caring for Our Children, third edition. We just wanted to clarify that they are two different things although Basics is a subset of Caring for Our Children, third edition. So we have heard from programs that they have been using Caring for Our Children, third edition for a long time. If you are doing that continue to do that, we don't want you to stop doing that because that has a more exhausted kind of list safety practices that programs can engage in.

Sangeeta: I just wanted to touch on 1302.91 as it relates to mental health. So often times we get questions around mental health consultant and what their qualifications should be. So we say that they must be licensed or certified mental health professionals. They do not have to have their PHD but they should be licensed in mental health or certified in some way around mental health. And ideally we would like that they have experience in serving young children but we know that this is not always possible. Sometimes is difficult to find a mental health professional in your area. And we say that if available in your community, then that person should also have experience in serving young children.

Marco: So one of the questions that we received is related to health procedures. Well, two questions, one is what is the definition for health procedures and then there is a list of — a list of things that were indicated. The question was to ask if these are considered health procedures that licensed professionals need to perform and these were particularly to blood glucose testing, for diabetes, epi-pens for allergic reactions, inhalers for asthma, and suppositories for seizures.

So, I want to highlight, I want to highlight the Staff Qualification, Standard 1302.91, the Competency Requirements. This is where the health procedures language is found and this particular standard says that — Health professional qualification requirements, a program must ensure health procedures are performed only by licensed and certified professionals. So the only reference I indicated to health procedures is this particular standard. To answer the first question, the standard does not include an explicit definition of a health procedure.

That said, we recognized that what constitutes a health procedure may be dictated by state or local levels or local laws or licensing requirements. So, we strongly recommend that programs should consult their Health Services Advisory Committee for guidance when planning to meet the medical needs of enrolled children. Further, programs are required to establish policies and procedures for administration of medication, so this leads me to the second question, which brings up the idea of — that relates to whether blood, glucose tests, testing for diabetes, administering epi-pens for allergic reactions, inhalers for asthma, suppositories for seizures, or administering other emergency medications would not be considered a health procedure.

So the answer to that question is no. So, as we move through this slide, we just kind of wanted to identify some available resources that we think are useful to you and we feel that they kind of address or they kind of highlight some of the Performance Standards or not — necessarily highlight, but they are examples of things we use to get information to kind of figure out how to implement that particular standard. So, along with what you are seeing, on the slide on the left-hand side of the screen, there are two — you are going to notice two documents.

One document is the PowerPoint that we used today and then the second document is titled "ECLKC Resources: Supporting the Head Start Program Performance Standards," and that document has a more exhausted list of the available resources on the ECLKC as they pertain to each section of the Performance Standards that we addressed today.

As we move through this we just kind of feel this — On the Purpose Resources, you'll notice that these are some the things that we highlight some pieces that you will find very useful to address, what the purpose — of the Health Section is. The collaboration and communication with parents’ resources, we have so many resources available that we have developed for families, tip sheets that help families understand concepts, and key concepts as it relates to health that can be what we are trying to achieve within our program.

One of the key underutilized resources that I just wanted to highlight to kind of help address the collaboration and communication with parents is our Well-Child Visit Planner. This planner allows parents to go into the planner and answer the questions, and at the end of going through the process, we'll get a print out that can be taken and/or email to the providers, to help address those questions, so when you are at the well-child visit you are not — lost for words about what are some of the key questions that you have, right? This is also, I think it’s really a nice thing that can be used with family service workers or teachers that are doing home visits to kind of help engage in some of these parents’ health activities.

There are more resources available to — I think this series of Welcome to Group Care is a very underutilized series, but it's an exceptional series, that one of the questions that we constantly get is why is my kid getting a sick? when they are starting the program, so this kind of help to address some of those issues of why kids get sick, we also developed it along a developmental spectrum, so depending on the age of the child, we are able to provide a tip sheet that goes along with that. It's a nice underutilized set of materials.

Our child health status, we have a number of resources that are available for child health status, everything from vision screening and how to identify or look at developing or using the vision screening process in your program. Going to ECO or we — we help to support ECO and helping us develop our hearing screening pieces that have been very useful to our program. So there is a lot material that is available there.

We have — a tremendous amount of oral health practices everything from our newsletters to webinars that you can actually hit play and show it to your parents. They were developed in that manner so that people can use them as supposed to develop their own webinars or their own training. It's something that you can just put on the screen and just hit play, just kind of go through that. We also a dental hygienist liaison program and I am sure that a lot of you have not heard about it.

Your regional TA folks and/or the National Center on Health has information — We have identified a dental hygienist in each state who is working with us on a volunteering basis to help programs as it relates to oral health practices in their programs, and they do everything from doing trainings to helpings identify oral health access to kids or for kids. So if you are struggling with oral health issues, please, use our dental health hygienist liaison, who is more that glad to help you out as needed, and if you can't get that information either reach out to your health TA specialist and/or National Center on Health and Wellness.

We have a number of nutrition resources. These are all based around healthy eating and physical activity. We are moving in a direction — So one of the things we constantly get is related to — and how that kind of works, so in the future watch out for our new material that help to address a lot of those questions. And then finally, we have a tremendous amount of safety practices resources that are available and with this all idea of active supervision the material is great, so please go online and look at it. Last year we came out with our staff qualifications and competency requirements for the health resources piece, and we develop health manager competencies by no means are these a requirement for anybody.

We just developed this because we thought that the field based on the health services manager study was looking for some sort of professional development ladder, so we put this together to help services managers kind of figure it out or professionalize the health service manager arena.

Sangeeta: So for mental health resources, we have a variety of things and I think it would be helpful to look at them. It reminds me when we were talking about the new provisions about parental consent. We have gotten some questions, wondering, how do we even have this discussion with parents as they are walking in, so we have some tip sheets that are pretty basic, but I think they will be helpful around what is mental health and what is early childhood mental health. So that can be something that you can go through with the parent and send home with them.

We also have some videos to help understand and address toxic stress, and we also have webinars and other materials that will health with early childhood consultation. We also have this new consultation tools. It hasn't been on the ECLKC that long. We are really excited about it. It has — It's very interactive, it has bubbles that you can click on that help you walk through what is mental health consultation, how to talk to mental health consultants, and so we encourage you to look on the ECLKC for that and go through this, this is the interactive series.

There is also this — This is something you can print out as well. It helps you to distress. I think that this actually help with staff loneliness. So, we have been to some programs where we have seen people to — around their center. And, it kind of help them to remember be mindful, to remember that you are doing a very difficult job, and take some time for your help as someone who is a teacher or staff or even parent.

Beth: Okay, so after all of those exhaustive run through of resources available specific to health. We want to also talk a little bit about some of the resources that are available more generally on the ECLKC, related to Performance Standards. So one thing that we want to highlight is our Showcase, which includes videos related to a lot of the core topics that the Standards cover. We wanted to highlight that there will be more videos coming to that Showcase on the ECLKC in February. We are going to have videos related to the general structure of the Standards, so how to navigate the Standards and how to read them.

A video about the requirements that are relevant to infants and toddlers, so that is relevant to dual language learners. A video again on suspension and expulsion, so if you still have questions we definitely encourage you to watch that video, it should be helpful. And then some specifics around the family child care option in terms of the requirements related to home-based option. So those are videos to look out for, they are coming soon. If you are not sure how to access the Showcase, we are going to walk you through right now as well.

So on the ECLKC, you'll see that one of the banners that rotates through has a picture of our Dr. Enriquez, and that leads you to the Performance Standards Showcase but or the Presenting the Standards, but you can also reach it by going to About Head Start, clicking on that tab and then there is a tab that says Presenting the Performance Standards. When you click on that you come to this lovely colorful page, which contains all of the resources that we have related to the new Performance

Standards. You can find the actual Performance Standards there, the preamble. You can also find the Showcase. So you'll see that one of the first tiles right there, when you click on the Showcase, you go to a — It takes you to a page that has all the different topical areas.

The very first video is an overview, the webcast that was done that covers sort of the whole Program Performance Standards. And there are videos that are specific to topics that you can access by clicking on the tile with the title that you are interested in. So that where you are going to find the videos we had up since, I believe September or November, and also the new videos that are coming. There will be an email that will go out that will announce they are available and you can find them here. This is also — Presenting the Performance Standards is also where you can find the webcasts from previous OHS Wednesday.

So you can go back and look at the webinars that we did starting in September all the way to December and then this one will also be posted on there and if you want to go back and rewatch and listen to some of Marco's answers, to some of those questions again. You will be able to do that through the ECLKC. The next thing that we want to highlight, as we have promised on previous webinars, copies of the Head Start Program Performance Standards are coming your way and they are coming your way soon.

So we wanted to highlight that multiple copies of the Performance Standards and the Head Start Early Learning Outcomes Frameworks, that was delayed over a year ago now, are going to be sent directly to every Center, grantees and the head offices, and the HSS CEOs. And so we really wanted to highlight why that happening, so we want to really — We really would want for teachers, staff, trainings really utilize these documents.

We are hoping that they won’t sit on a shelf, by providing had copies of them they will really be able to utilize by your teachers, home visitors and other relevant staff. We are also providing copies, hard copies of the preamble, which are being sent to grantee and delegate head offices. And that's because that we reiterate that preamble really does provide a lot of information, some places that you can go and really, sometimes find an answer to your question, without having go through process and wait.

If you read the preamble sometimes some of these clarifications are really already available there. Spanish copies are being sent in proportion to number of children who's primarily language is Spanish, according to the 2016 PIR, and you should be looking for those to arrive sometime around the end of January. So we are really excited about that. We are hopeful that by sending out these hard copies, we really will be able to get in the hands of staff and have a more comprehensive understanding throughout the entire Head Start community of what the Standards are doing and how to implement them. So with that.

Ann: Well, I have lots of thoughts. I realized that I need to – There is a lot to learn— but I think this generated — We got over 151 questions, just in this very short period of time. And I think it was interesting because when Colleen started off, trying to clarify a 3-year-old right away and she said, "Now, I got to go to Standards" -- We cited the citation and wrote the text. And I think for our TA providers we really got to exercise such discipline to keep the book with us, and whenever question is asked go to the book because so often the answer is right in the text to the regulation.

The other thing, I think it also reminds me and Marco. When you were talking, “They are streamlined, they are in the right order and sequence, and they make sense,” but they are still a huge amount to absorb. And these webinars, I think they are just one piece, and the resources are one piece, but this is really, this takes, I think a discipline and a vigilance throughout the year, to really feel that you got a level, maybe the beginning level of mastery is — this is a yearlong commitment, if not a lifelong commitment. The other thing I thought is — As I look at 100 figure, we can see the questions coming in. And I had — At one point I thought, "I can't believe someone is asking that question" and then I realized, many of us in this room has been around Head Start for — 25 years.

So we have talked about these things and we know them. We have to remember, even within our TA audience, there are people coming in at every level. People that knew nothing about Head Start but have excellent expertise in the health area. So I think it's just a reminder to us that some of these questions might seem like old, they are not old, there are may be old to us but they are brand new to the people that are asking them for the first time and they are being part of the Head Start community for the first time.

So it's a kind of like a sensitivity, sort of reflection from me. And I think — Where do we go from here? I think about — Sangeeta when you were talking about exposure and the rush of questions that came. I hate the expression — but I think we have to figure out how we can just have a conversation for a long period of time about one tiny subject but has huge implication. And I think that's kind of something that grantees got to grapple with, we got to grapple with and our TA folks. And the last thing I think I want to say. There was one question that came in and I — probably a new person and reading the regs., kind of thinking about the expulsion, thinking about what Marco said about the immunization, and there got be on schedule.

And a person said, "If a child is a couple of weeks late on getting immunization should we expel the child?” And I think — I mean I think the good depiction of helping someone say, Head Start is all about not a reputable or adverse actionate for a parent, that we must be relentless in our efforts to support parents to get to the point where they understand why is that meaningful that the child stays on schedule.

And I think someone says, it might have been Colleen, tell me if I am misquoting you here, but even around the issue on exposure, there is a lot of discussion about that, you say almost, you can't do it. And I think it was Colleen who said, "We really intended to make it really tough.” We set the bar really high. That if you are ever at the point where you ever reach that limbo period and the bar is so high, and that was intentional. So I think we just want to bathe our families in support as well as our staff, so they can get parents and children to a better place.

So this is — I am discouraged that I don't know as much as I thought, Marco and Sangeeta, it's just making me want to learn more. So, are there any other closing comments or thoughts from our colleagues around the table?

Sharon Yandian: Next month reminder of the date. Ann: Go to it, Sharon.

Sharon: Yes, here it is, February 15, I think is family engagement.

Coleen: Yes, that's right. So, join us on Wednesday, February 15, we will be covering family engagement as well as early childhood system, so some of these big questions that we know we have got related to those topics, will be hoping to address with more clarity then. Thanks everyone.

All participants: Thank you.