The large numbers of infants and young children with developmental and physical problems who are at risk for or who are already demonstrating signs of emotional disturbance create significant challenges for implementing community level services to prevent and manage these problems. One of the primary challenges in most communities relates to the fact that services and fiscal reimbursement patterns are organized along specific categorical lines (eg, medical care, mental health services) and involve self-contained programs that focus on specific categories of problems (eg, children with physical illness, developmental disorders, etc.). Moreover, the funding and reimbursement patterns that support services also tend to focus on children with specific disorders. One example of a reimbursement strategy that has particular relevance for the support of mental health services for infants and young children is the "carve out" or separate reimbursement of mental health service in a contracted service that is separate from the family's health plan. 1 Another example is the deployment of funds at a community or state level as "mental health dollars" that are earmarked only for categories of children with specific mental disorders.

The isolated, categorical deployment of services and reimbursement patterns has several critical undesirable consequences: Such patterns of care and funding do not address the fact that some developmental and physical vulnerabilities and disorders place children at high risk for mental health disorders. Moreover, many children have comorbid physical, developmental, and mental health problems that require comprehensive, integrated approaches to diagnosis and management. Many emotional and mental health problems have a direct bearing or influence on the outcomes and functioning of infants and young children who also have developmental and physical problems.

Patterns of service deployment and reimbursement that are prevalent in many communities not only fail to consider the potential value of comprehensive interventions that address multiple categories of problems and may even pose barriers to such interventions. Nevertheless, mental health interventions for children with developmental and physical problems may improve outcomes in multiple domains of functioning and have significant benefits in terms of cost saving for services in other systems (eg, educational and health care). For this reason, the complexity of comorbid mental, physical, and developmental problems that present in many infants and young children require creative approaches to coordination and integration of diagnosis and intervention that address problems in multiple areas.

Finally, existing patterns of care and reimbursement in many communities may ignore practice realities. Many of the most significant clinical challenges that are faced by professionals who work with infants and young children with developmental and physical problems often relate directly to the need for interventions for their emotional problems.

The formidable challenges that are created by limitations in the integration of services address the child's developmental, physical, and mental health needs and require complex solutions. In many communities, this problem is defined as not having sufficient access to trained mental health professionals for referrring infants and young children with a significant behavioral or emotional problem. The lack of trained mental health professionals and problems in access to mental health care are in fact very significant problems. However, the challenges of service provision are much broader and reflect the fact that systems of care delivery in many communities lack adequate coordination and integration of care for infants and young children with developmental, physical, and emotional problems. This can have the following undesirable consequences: (1) mental health services are delivered apart from the specific context of care for medical or developmental problems; (2) diagnosis, treatment planning, and management of children's developmental, emotional, and physical problems are not coordinated across different systems and settings; (3) funding and reimbursement of services to infants and young children who have complex physical, developmental, or mental health problems may limit access to appropriate care; (4) professional diagnostic and management plans that are developed to deal with multiple problems which can engender distress and confusion in the minds of parents who may wonder: which is the most important service? what should I do first? how can I afford all these treatments? For this reason, it is not surprising that a recent national survey of families of children with special health care needs indicated critical problems including problems in coordination of services and problems in obtaining specialty services. 2

For the above reasons, a key challenge in service delivery for infants and young children relate to coordination and integration of care across various services. Coordination of care involves linkage and organization of care across different systems (see Harbin et al 3 for a cogent discussion of this issue with a focus on young children with disabilities and their families). Over and beyond coordination of care lies the challenge of integration of care, which relates to the degree to which services in different areas (eg, health or mental health) are delivered at the same time in the same setting. Given the complexity and multifaceted nature of the problems experienced by infants and young children and their families, integrated service models are few and far between. Nevertheless, there are models of care delivery to emulate and promote. For example, Knitzer 4 has provided a thoughtful discussion of how one might develop and implement an integrated early childhood mental health services delivery system by integrating mental health principles into core health home visiting, and early intervention programs, etc. My hope is that the contributions in this special issue will inspire the readers to develop and describe models of innovative programs of integration and coordination of care across systems of care delivery for infants and young children.

REFERENCES