Assessment of New Hampshire’s Early Childhood and Family Mental Health Workforce

Executive Summary

While mental health services have historically been targeted towards adolescents and adults, there is growing recognition of the need for increasing the availability and capacity of services and programs to promote healthy social, emotional development for young children and their families. The Endowment for Health and the New Hampshire Children’s Health Foundation commissioned an assessment of the capacity of the workforce serving this population in the New Hampshire. The objectives of the assessment were:

  • To identify who is providing early childhood and family mental health services, where, how, and with what training and credentials.
  • To identify barriers, beyond those of financing, to providing and accessing early childhood mental health services.

“Early childhood mental health services” refers to both clinical mental health services and child and family strengthening programs (e.g., home visiting, family resource centers). The inclusion of family strengthening programs is consistent with the New Hampshire 10-year Mental Health Plan. The assessment used a mixed-methods approach, including key informant interviews, focus groups, a survey of providers, and collection of secondary data (e.g., Census and administrative data).

Key Findings

There is no one singular system of care designated to deliver early childhood and family mental health services in New Hampshire. Overall, early childhood and family mental health services were described as disjointed, siloed, and, in some cases, non-existent. Assessment participants detailed the difficulty that families experience accessing and navigating care, perceived as arising in part from a lack of communication and coordination between the different services and providers that fall under the umbrella of early childhood mental health.

There is a widespread shortage of qualified mental health providers across the state. Limited workforce capacity in the fields of mental health, early childhood education and development, and family support arose as a major challenge across the state. Participants attributed workforce shortages and high staff turnover to low wages and reimbursement rates and burdensome credentialing and training requirements. Participants indicated that provider shortages led to long wait times for services and families being bounced between providers due to turnover. The lack of consistency was perceived as disrupting care and making it difficult to continue with programs or treatment. Assessment participants largely agreed that, while the Early Childhood and Family Mental Health (ECFMH) credential training and reflective practice requirements are valuable, its larger impact is limited. Participants perceived that larger recognition of the credential was low across the state.

The high cost of evidence-based models prevented them from wide-spread implementation across the state. Participants identified several effective models, such as Healthy Families America (HFA) and Child- Parent Psychotherapy (CPP), currently being used in New Hampshire. Participants cited the high cost of trainings and the loss of billable time as preventing more staff from being trained in evidence-based models.


Recommendations from the assessment fall into four overarching categories: A statewide early childhood mental health system, workforce development strategies, increased availability of services, and reduction of structural barriers.

Develop a Statewide Early Childhood Mental Health System | To facilitate children and families accessing the care they need, New Hampshire should establish a coordinated early childhood mental health system of care, including infrastructure around training, monitoring, and administrative support to assure adequate reimbursement, as well as expansion of services across the continuum of care.

Strengthen State Level Credentialing | Advocates and legislators should partner with the New Hampshire Association for Infant Mental Health to develop and advocate strategies to elevate the ECFMH credential statewide. Potential strategies could include requiring the credential for specific provider levels or associating the credential with increased salary level or higher reimbursement rates. Offering scholarships or reimbursements from the state to cover costs associated with the training would also incentivize providers to take part in the training.

Increase Support for Training | Additional support for on-going provider training arose as a need. This could be done by offering subsidies for the cost of attending trainings and offering more trainings in rural areas. Increasing virtual training opportunities and improving the technological infrastructure needed should also be explored. Changes to billing rules to allow training attendees to bill for time spent at professional development opportunities would also incentivize more providers to participate in trainings.

Increase and Expand Payment and Reimbursement Rates | Assessment participants cited higher reimbursement rates as key to supporting training needs and strengthening the workforce. In addition to increasing reimbursement rates for services, improvement could be seen by advocating for an expansion of billable services to include more services offered by Family Resource Centers and home visiting programs. Workforce challenges could be addressed through increasing salaries for early childhood and family mental health providers. Financial incentives, such as tuition reimbursement or loan repayment, could be offered to recruit and retain providers.

Co-locate and Integrate Services | Participants recommended embedding mental health in systems that already serve children to improve access and increase awareness of available mental health services. This could be done by integrating mental health providers in Family Resource Centers, Family Centered Early Supports and Services, early care and education settings, and the Division of Children, Youth and Families.

Increase Availability of Services | The need for more services was identified across the continuum of care. Efforts to support workforce development would incentivize and support providers in increasing their offerings for the target age group. Participants recommended increasing the number of services offered in rural areas. Participants also recommended increasing Medicaid reimbursement for early childhood mental health care to enhance services for Medicaid patients.

Reduce Structural Barriers | Steps should be taken to reduce structural barriers to families accessing needed care. Recommendations include funding transportation credits (e.g., taxi credits), improving marketing of existing transportation programs to raise awareness among qualifying families, and providing subsidies for childcare. Increasing availability of home-based services and weekend or evening appointments would also reduce structural barriers.

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