For 20 years, Clara’s House, a behavioral health program based in St. Cloud, has been a place of respite for children ages 5-18 who struggle with mental health concerns. In recent years, the CentraCare-run facility, a partial-hospitalization program — with intensive, day-long therapy combined with school instruction to keep young participants on track academically — has been fielding an increasing number of requests from parents and care providers searching for mental health care for toddlers and preschool-age children.
Barbara Skodje-Mack
Barbara Skodje-Mack, CentraCare director of child and adolescent behavioral health, chalked some of this increase up to a growing cultural awareness and treatment of mental illness in even the very youngest children. “We have integrated behavioral health therapists in our primary care settings now,” she said.
When a parent brings their child to the pediatrician for a routine visit, Skodje-Mack explained, young patients are regularly screened for mental health concerns. This approach is uncovering mental health issues in young children, she added: “We are seeing greater demand for early-intervention services, which is great. Just like any other medical condition, the sooner we can spot a mental health issue and provide therapy, the better the outcome for the parent and the child.”
While the growing presence of behavioral health providers in pediatric clinics leads to more mental health diagnoses in children, a more accepting attitude about mental illness and its impact also plays a role in the growing interest in programs like Clara’s House, Skodje-Mack said.
“Our society is recognizing and talking about mental health and trauma and taking care of our mental wellness much more than we did in the past. We are also paying attention to and understanding early brain development, how significant traumatic experiences can be in the first five years of life and how those experiences build core brain development. This shift increases interest in our services.”
In response to this growing need, Clara’s House administrators made plans to expand their offerings to include mental health services for children as young as 3 years old. The CentraCare foundation raised the funds needed to add a 5,785 square-foot early-childhood unit to the program’s existing building. The addition includes space for two group rooms, psychiatry services, psychological testing and art and recreational therapy, as well as occupational and family therapy. Construction is nearly complete, with a grand opening scheduled for Jan. 27.
While there are already a variety of agencies in the state that provide mental health services to children ages 0-5, Skojde-Mack said Clara’s House will be “the first in the Midwest to have a partial hospitalization program for these earliest ages.”
Jeffrey Reed
Jeffrey Reed, a psychotherapist who has worked at Clara’s House for eight years, said early intervention is key to the successful treatment of mental illness in children.
“The earlier we are able to intervene the better,” Reed said. “At these young ages, critical brain development and attachment are happening. If we can get to mental health issues sooner, we’re more likely to be able to help family systems understand the significance of these issues and change their path.”
In the years leading up to the early childhood expansion, Clara’s House has been enrolling what Reed describes as “some very fresh 5-year-olds” or “kids at the very tail end of what we generally accept here.” Even though these participants seem young, Reed said he and many of his colleagues wish they would’ve been able to intervene even sooner. “We can see we’ve waited too long, that many of these issues have been going on for some time,” he said.
Much of this has to do with limited availability of mental health care options for young children. “Parents were waiting a long time to get this kind of intensive care,” he said.
Though staff could see that they needed support, Reed said some of those fresh 5-year-olds struggled to find a place in programming designed for older children. “They have been hard to manage,” Reed said. “It felt like our program wasn’t equipped with the right space and the right interventions for them.” The new early-childhood addition is designed to better meet the developmental needs of these young participants, he said: “The way the program will work with the right equipment and interventions for their age group will be excellent.”
What brings kids in
What kinds of behavioral issues inspire parents and pediatricians to seek mental health care for very young children? To the untrained eye, some issues may appear to fall under the category of “normal” toddler or pre-school behavior, Skodje-Mack said, but are actually more intense and difficult for parents and other caregivers to address.
“Sometimes, we will have situations where the parents are reporting their child isn’t sleeping well, is refusing to eat, is having frequent and intense tantrums,” Skodje-Mack said. In many children, she added, “Tantrums are normal, but these would be intense tantrums or negative behaviors that are interfering with daily activities. Some kids are being told they can’t come back to childcare settings due to their behaviors and uncontrolled emotions.”
Reed said he and his Clara’s House colleagues see a range of behavioral concerns, including “hitting, kicking, elopement, biting, being destructive in terms of throwing objects around the room and damaging property.” Some young children even exhibit suicidal statements and self-injurious behavior. Sometimes the youngest children exhibit the most intense symptoms, he added. “We’ve got our hands full with some of those younger students,” he said.
Behavioral health symptoms in young children often are a reaction to early traumas they have witnessed in their households, Skodje-Mack said. Other times, the behaviors may be a symptom of a larger developmental concern. “We are able to do early psychological testing to assess whether there are learning needs or neurodiversity needs,” she said.
Exhibiting intense, negative behaviors may be a young child’s only way of expressing their emotions around formative negative experiences, Reed said. “When a young person has experienced scary life events repeatedly, it causes a hypersensitivity to stress. Maybe something small, like having to transition from one setting to another, creates a very large amount of hyperarousal for a child.”
Typical diagnoses for Clara’s House participants include, Reed said, ADHD, autism spectrum disorder, disruptive mood dysregulation disorder, depression and anxiety disorders. Because young children lack the vocabulary to clearly explain how they are feeling, their mental health symptoms may present in ways that feel confusing to adults, Skodje-Mack said.
“Sometimes people think of these symptoms as behavior outbursts or tantrums,” she said. “If we look a little deeper we might see that the root of that anxiety might be about the family system and the dynamics in their home.”
While many Clara’s House participants come from intact middle-class families, Reed said that others come from households that are experiencing financial upheaval and personal struggles. In those cases, adult stressors can trickle down to the youngest family members.
“We see a lot of single parents that are struggling emotionally and financially,” Reed said. “They lack support. In my experience of being a child therapist, one of the largest underpinning reasons for these kids to be struggling is a struggle in the family system.”
In acknowledgement of the key role parents and other caregivers play in supporting the mental health of children, Clara’s House requires parents to attend regular therapy sessions with their children. “There are family sessions both with the child and without the child,” Skodje-Mack said. The child-free sessions focus on “providing parenting skills education and advice for raising young children in an emotionally healthy manner. These are skills that have a long-lasting impact.”
A place of respite
Clara’s House programming is intense and tightly scheduled, Skodje-Mack said. Children come to the program every weekday for as long as six weeks, and children in the early childhood program may participate for as long as 12 weeks: “They don’t stay overnight. They go home to their families, but it is much more intensive than seeing a therapist once a week.” For older children, school classes are included, as well as a variety of therapy modalities, including individual therapy, group therapy, recreational therapy and family therapy.
The self-contained facility was designed to put young participants at ease. “We have a really great space that feels comfortable,” Skodje-Mack said. “It doesn’t feel like a hospital.” In the new early-childhood wing, she explained, “We have two group rooms that are set up for kids to be in. They look like a childcare setting. The therapy isn’t like therapy for adults. It is engaging and play-based.”
Clara’s House is small by design, and the early-childhood program will be no different, Skodje- Mack said. “We are planning to have five to six kids in each group room for a total of 12 as a cohort,” she said.
Reed said Clara’s House’s personal, focused approach to therapy helps young participants achieve their mental health goals in a relatively short period of time. “The [older] kids are here in place of school,” he said. “You get to connect with them on so much more of a deeper level. That’s what’s neat about the work: We really get to know our patients. We really make an impact on them in a positive way.”
While an intense, multiweek program focused on mental health may sound exhausting, Reed said most children who spend time at Clara’s House find the experience relaxing and freeing — a safe, hopeful space where they can process their feelings and emotions without judgment.
“It’s a breath of fresh air,” he said. “When they are with us, these kids feel like they are on a bit of a vacation. I don’t mean to say we shower them with prizes and luxury, but we do shower them with praise. We give them a lot of reinforcement, reassurance and validation. By the end, they seldom want to leave. They just love it here.”
Andy Steiner
Andy Steiner is a Twin Cities-based writer and editor. Before becoming a full-time freelancer, she worked as senior editor at Utne Reader and editor of the Minnesota Women’s Press. Email her at [email protected].
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