This story was supported by the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems. 

When the calls started coming in about Ryder, Amy Walthall couldn’t understand what had gone wrong. He had bitten a preschool classmate one day. Tried to choke another. He wouldn’t stop yelling. 

Her son had a rage that wasn’t there before. He was violent, and parents were complaining — they wanted him out. She saw the stares when she dropped him off. Who is Ryder going to bite today? she imagined the other parents thinking. 

Teachers didn’t know what to do with the 4-year-old. They isolated him in a room, sometimes for the entire day with just an aide, to keep him from hurting the other students. It wasn’t long before he was suspended from his Arkansas preschool for three days.

Walthall considered taking him out of school for good and leaving her job as a nurse to care for him. Her family, which included two older daughters, stopped going anywhere to prevent what was happening at school from happening anywhere else. She sunk into a deep depression. 

There is something wrong with my child, she thought, again and again. But what? 

Sometime during that turmoil in 2018, their preschool brought in a mental health consultant to observe Ryder. The service came through Arkansas’ Project PLAY, a fairly new program that was working to bring down the high expulsion and suspension rates for children in child care settings by embedding mental health consultants to help train staff to care for them. 

Absent the kind of mental health support and disciplinary structure already in place for older children in the school system, kids in daycare and preschool are expelled at about three times the rate of kids in K-12, a staggering statistic that flew under the radar for years.

Now, mental health consultation has emerged as one of the most effective methods to help curb the rates of expulsion, which, if left unchecked, could splinter children’s social, emotional and educational development. 

The arrival of his consultant, Elizabeth Waldrum, changed Ryder’s course.

He’d just been diagnosed with a severe sensory disorder, which causes some of his senses to be heightened and others, like touch, to be severely lacking. It’s why loud noises set him off and why he got physical with other kids. He was also then diagnosed with PANS, a neuropsychiatric disorder that is distinguished by the extreme and sudden change it causes in children — sometimes overnight.

The preschool didn’t have a system in place to give Ryder the structure he needed. His consultant filled that void, one that is common across the child care industry more generally. Already, child care centers barely get by due to the high cost of running the business with enough staff to meet child-to-teacher ratio requirements. Staff earn close to minimum wage, and parents pay high prices just to keep centers operating. There is little left for professional development and additional support like mental health. 

The consultant in Ryder’s preschool helped guide the center toward what it needed to do to support kids like him. She created a visual schedule of the day to ease his anxiety, so he always knew what was next. She worked with him to better express himself, and taught the staff and his parents to speak to him in a way that acknowledged the stress he was under. She helped send out information to parents about Ryder’s diagnoses and created a room for him to go if he needed a break from sounds or the other kids. 

“I can’t even express how important it was,” his mother said. “Being willing to help and to see him as not a troubled kid, not a bad kid.”

Walthall credits the mental health consultation work that was done with Ryder as being the single thing that ensured he could go to public school, where an infrastructure for mental health support has been in place for decades. It was also what kept her employed, and freed their family from the threat of financial instability. Without the early intervention, “we would have all suffered in the long run — financially, emotionally, physically, psychologically,” Walthall said. 

Now in second grade, Ryder no longer needs an aide to watch him during the day. He can express with clarity what he’s feeling and when a situation is too much for him, so he removes himself before things take a turn. He likens himself to the Hulk, who is working on controlling his anger, too.

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Over the past decade, there’s been a sea change in the way child care providers think about mental health, and that has opened a pathway to creating a more sustainable industry. Mental health consultation has a trickle down effect, helping not just individual students, but their classmates and teachers. In studies, educators have reported feeling empowered through mental health consultation, a shift that could improve retention and outcomes for the women who make up 95 percent of the child care workforce.

Seminal studies in the 2000s from Yale University researcher Walter Gilliam, the nation’s top expert on the subject, started to peel back the disproportionate impact of expulsions and suspensions on younger children, which particularly impacted Black boys. 

Oftentimes, expulsions were happening because of stress in the family, or the community. Sometimes, that stress weighed on providers, Gilliam said. 

“What happens is the providers don’t get the support they need and then they expel the child. And when you expel a child, they don’t vanish, they don’t cease to exist. They just go someplace else and become a concern for somebody else who isn’t well resourced,” Gilliam said. “Instead of expelling children from child care programs serially until they land in a clinic, what if we expelled the clinicians out of their clinics and put them in child care programs?” 

Gilliam and others pushed Congress to require that states bring down their expulsion rates by tying it to the Child Care and Development Block Grant, the main funding structure for subsidized child care programs across the country. It passed in 2014, so any states receiving that funding had to comply with the new requirement. By 2016, mental health consultation seemed to be the best bet for driving down rates. 

Arkansas was one of the states that got on board with mental health consultations early, and it has had returns: Arkansas’ expulsion rate has come down from about 9 percent to about 3 percent. The national average is 10 percent.

The state provides a three-tier consultation system depending on the severity of the case. Project PLAY is the third tier, where consultants go into classrooms for three to four months of weekly visits to create a plan for teachers and parents. Referrals to the program increase by about 40 percent every year, said Dr. Nicola Edge, the director of Project PLAY and a professor at the University of Arkansas for Medical Sciences.

We see mental health consultation as an equity practice and an anti-racist practice.

Kadija Johnston, professor at Georgetown University’s Center for Child and Human Development

Nationally, 26 states that previously were not doing anything on early childhood mental health consultation now have programs or are preparing to launch programs. Fifteen states have banned preschool expulsion altogether. Additional funding for child care through the American Rescue Plan passed earlier this year is equipping states to expand such services, with guidance from the Biden administration specifically encouraging states to use some of the money for early childhood mental health consultation. A potential historic infusion of $225 billion to the child care industry through President Joe Biden’s proposed American Families Plan could take mental health consultation from an added service in some states to a fundamental piece of the child care infrastructure across the country. 

“I can’t think of a time where we’ve had more bipartisan support and interest in child care in my career than right now,” Gilliam said. 

What’s happened in the past few years has been a deep realization that child care was falling short on every level — at the cost of children’s development.  

“The moment-to-moment experiences of infants in the first three years of life really determines the architecture of the brain, as well as casting a long shadow — for good or for ill — to who any of us become,” said Kadija Johnston, a professor at Georgetown University’s Center for Child and Human Development. Johnston worked in one of the first infant and early childhood mental health consultation programs in the country at the University of California San Francisco. It began in the mid-1980s. 

The other thing that has changed in recent years is a greater understanding of how the deep-seated racism of the educational system was hurting kids even in child care settings. Gilliam’s work has also uncovered that though Black preschoolers make up 19 percent of enrollment, they were nearly half of all preschoolers who were suspended one or more times. 

Women of color also make up nearly half of all child care workers, a legacy of slavery when Black women cared for the kids of White people that is still reflected in the workforce today, Gilliam said.

Johnston believes that mental health consultation could be an integral part in reversing course. 

“We see mental health consultation as an equity practice and an anti-racist practice, a potential dismantler of racism in an institution, like all institutions in our country, that struggles with and suffers from structural systemic racism,” Johnston said. 

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It could have been years before LaTonya Gueary learned that one of the children under her care had autism if a consultant hadn’t come to her at-home care center to observe. 

The 2-year-old boy’s parents thought he was just acting out. There are many times when a parent doesn’t want to acknowledge that something is wrong with their child, she said. But Gueary knew something was off — the boy was non-verbal, but he would squeal and squeal, she said. She just didn’t have the resources to identify what it was. 

Gueary had spent more than two decades in child care working at a daycare center where she had been given classes and training. But she’d never learned how to work with children who had autism. She had even less support now — over the past 15 years, she had moved to providing care from her home in Baton Rouge to six kids between the ages of 2 and 4. 

At the same time, Louisiana had been developing one of the most robust child care mental health consultation programs in the country, sending consultants to centers that have the most need — including at-home daycares — for six months or more.

Gueary’s consultant, who she calls Miss Karen, visited her every other week and quickly identified that the boy was likely on the autism spectrum. She showed Gueary how she could better communicate with him, clearly and on his level, and encouraged her to learn sign language, which she took on right away. The tools she gave — the worksheets, the videos and the hands-on instruction — were also shared with the parents who started taking him to a speech therapist. 

That was a year ago. The boy, now 3, can speak. He knows his name, the colors, the numbers, his ABCs. Gueary understands now that what caused his screaming was the loss of structure. He likes to line his toys up by color or type, and when that got disrupted, he’d shout. He had no mechanism to communicate. 

The help, for Gueary, also got at the deep need for support within her industry. When she worked in daycare settings, turnover was high (in some states, annual turnover is as high as 40 percent). 

“They didn’t last a week. They’d walk off the job because they are like, ‘Man, this isn’t what I thought it was.’ They really don’t know the field. When situations arose, they didn’t know how to handle it,” Gueary said of her former coworkers. 

That turnover is detrimental for kids, but it’s also disheartening for staff, who often leave for other low-wage jobs that have better incentives or pay slightly more. The median hourly wage for child care workers in the United States is $12.24 — lower than that of housekeepers and retail sales workers.

“They deserve to do work that is the most essential work there is to do and I think we have failed as a nation to grapple with that. I think we know the reasons: Who does the work is primarily women and who receives the work is primarily children,” Johnston said. 

 “So populations that rarely have a political voice.”

Mental health consultation is one avenue to begin to value caregivers, because it empowers workers. 

“What our consultants will tell you is that oftentimes they are working with a teacher who has very little support and validation and encouragement and that they may be the only person telling them, ‘You are doing such important work and you’re doing it so well and of course you’re struggling to support this child,’” said Edge, the director of the Arkansas program. “Just to validate them and to help them feel heard and important as they are, that’s what our consultants would say is one of the most important things they do.” 

And that need is becoming even more important. Since the pandemic began, severe cases of stress, grief and abuse have surfaced in children and in providers. Teachers who worked through the pandemic did it with fear of contracting the virus. They still do — young children have not been cleared for vaccination. Many have endured significant personal and financial losses. 

Preliminary findings in a study now underway by Gilliam and researchers at Yale of 57,000 child care providers has found that depression rates among educators are up four times from where they were pre-pandemic. 

“The amount of stress that these child care providers have in their normal life is quite immense. And then they take upon themselves the stress of the world because every child puts the stress of their family and their community in a backpack and in their lunchbox, and takes it to child care. And the child care provider has to manage that, too,” Gilliam said. 

States like Louisiana are already looking to expand their services to better help child care workers. This year, they set up a tele-health hotline for workers or parents — anyone who is caring for a child under 5 — to call if they wanted to speak to a mental health consultant. 

Their consultants have helped moms looking for a shelter because of domestic violence, they’ve provided grief support when there was a death in the family and they’ve helped workers who needed their own mental health support. 

It’s like a web, said Allison Boothe Trigg, the executive director of Tulane Mental Health Consultation Services and the director of TIKES Early Childhood Mental Health Consultation and Support program at the Tulane University School of Medicine in Louisiana. 

“It starts with that consultant and that connection to a center, and then the web just grows,” Boothe Trigg said. “After we’ve left that center, we’ve supported that teacher [and so] she has different ideas, she knows who to reach out for help and so she continues to impact the children in her care as she moves on.”

And while much of the mental health consultation process is still in early stages in many states — there is need for more consultants, more funding and longer-term models — so much of the work so far has shown the difference that comes from equipping a workforce with the tools to do the not-insignificant job of raising the next generation, Boothe Trigg said. 

“The impact of having someone who listens and treats a teacher or a director with respect and as a professional, that helps them think about their work — I don’t think you can put a dollar amount on that relationship that then supports so many other relationships.”