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No Wrong Door for Early Childhood Intervention: Is there a screen?

CAPTA SummitPenny Knapp MD

Medical Director, CA DMH1/23/08

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Social and developmental realities How many children are in the system? How are they faring, developmentally? Evidence on the effectiveness of early

intervention The utility of early childhood screening Strategies for improved coordination of

services

Topics for today

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Substantiated abuse/neglect for children ages 0-3 – about 27,000

Children in out of home placement: aged 0-3: as of 12/06:

11,673 in-home, 15,764 – foster care (more than half

of substantiated cases)

Part 1 Children in the CWS system

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Attachment disrupted Neglect or trauma early in life Loss of safe context Developmental risk Risk of social-emotional disorders

What does this mean for the young child?

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The critical importance of attachment

HEALTHY ATTACHMENT DISTURBED ATTACHMENT

Reciprocal cuing, shared joy Reduced reciprocal attachment

Child turns preferentially to “mom”

Child does not seek comfort from “mom” when distressed

“Mom” is able to comfort child Child fails to respond to comfort

“Mom” helps child regulate emotions

Child has poorly regulated emotions, e.g. limited positive affect, and/or excessive irritability, sadness or fear

Child is free, in “mom’s” presence to explore, learn

Child is preoccupied with making or maintaining contact with “mom.”

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Trauma

Child is overwhelmed and may:

• Dissociate• Be hypervigilant

(+/or “hyperactive”• Have disturbed

sleep, appetite, concentration

DC 0-3 diagnostic criteria

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The Diagnostic Classification for Children Zero to Three.

www.zerotothree.orgA 5-Axis diagnostic system, parallel to the DSM-IV

except for Axis 2AXIS 1 - Psychiatric disorderAxis 2 - Relationships (In DSM-IV, Personality

Disorder)Axis 3 - MedicalAxis 4 - Psychosocial stress, Axis 5 - PIR-GAS

Can we diagnose mental disorders in children 0-3?

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If something goes off-course as the baby develops to a child, what are the off-course pathways?

A Sudden Example: Post-traumatic stress disorder B Continuous Example: Developmental Disorders - Mental

retardation, Autism C Cumulative: Example: Regulatory disorders (DC 0-3)

What are the stakes - for the child?

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Dx requires both a distinct behavioral patternand a sensory, sensory-motor, or organizational processing difficulty.

Type 1HypersensitiveType IIUnder reactiveType III Motorically Disorganized,

ImpulsiveType IV OtherRegulatory disorders underlie many or most

psychiatric diagnoses in children

Regulatory Disorders (DC 0-3)

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Maternal depression

The highest risk for first episode of major depression is during childbearing years

Prevalence: 10-15%. If left untreated, 30-

70% experience depression for a year or longer.

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Maternal depression - impact on the child

Children of depressedmothers have• Behavioral

problems, • Emotional

problems, • Problems with their

own relationships later in life.

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Children in foster care with developmental problems - 50—60%

With medical problems – 80%; 25% with 3 or more problems

Double jeopardy: children with disabilities are maltreated 1/7 x more.

How do CWS children fare, developmentally?

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Percent of annual Early Start caseload that are CPS referrals – 6,300

(15% of EI, caseload, @23% of substantiated abuse/neglect cases, @ 47 % of children in foster care)

How many get referred for Early Intervention?

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Brief review of evidence• Published evidence of efficacy of programsSuccessful applications in California• IPFMHI• Best PCP (ABCD II)• CIMH development teams for EBPs

Part 2 - Evidence re. the effectiveness of early intervention

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(Primary Prevention) Home Visitation (e.g. Olds Nurse Home Visiting, Hawaii Healthy Start)

(Secondary Prevention) interventions with depressed mothers, abused/traumatized mothers, dyadic interventions

(Tertiary Prevention) Incredible Years, PCIT, Multidimensional Treatment Foster Care

(Multiple Levels) Triple P: Positive Parenting Program

Examples of successful prevention programs

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IPFMHI Infant Preschool Family Mental Health Initiative 2001-05. State First 5

BEST-PCP Behavioral Emotional-Social & Developmental Screening & Treatment in Pediatric Primary Care - CW/NASHP 2002-2005

SECCS State Early Childhood Comprehensive Systems

Recent State Initiatives

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1 Early Mental Health Initiative (EMHI) - At-risk children K - 3. Run by DMH - legislative appropriation

2 CIMH Development teams to implement evidence-based practices

www.cimh.org

3 ABCD Screening Academy

All are successfully using standardized screening tools

Current CA activities

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Third in ABCD series, funded by CW, admin by NASHP.

Focus on screening for developmental and mental health problems in 2 pilot counties (LA, Orange)

Opportunity to move toward long term plan to make screening a standard activity

Lead (CA DPH) Janet Hill

ABCD Screening Academy

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4 ABC - Assuring Better ConnectionsLACDMH received a SAMHSA grant for SOC for 0-5

to explore and catalyze development of comprehensive systems of care for children 0-5. Bill Arrroyo MD & Marie Poulsen PhD lead.

5 EDSI: Early Developmental Screening and Intervention Initiative:

LA First 5 $ to develop a collaborative to improve developmental and preventive services. Moira Inkeles MPH PhD

Current CA activities, cont.

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5 First 5 Social Emotional Health System Development Project

In a 2-year time frame the group is to identify barriers (to) and develop strategies to provide improved screening and services to very young children and their families.

Funding from The California Endowment to State First 5 association

Current CA activities, cont.

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• Zero to Three www.zerotothree.org• American Academy of Pediatrics: Bright Futures,

Mental Health Task Force etc. www.aap.org• American Academy of Child & Adolescent Psychiatry

www.aacap.org Practice Parameters, Facts for Families• NASHP www.nashp.org As part of ABCD II program, NASHP surveyed all State

Medicaid, MCH and MH agencies to evaluate practices for 0-3. e.g. Coordination of services with Part C, ECE

Recent & current initiatives -National

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Medicaid Program Strategy Use of Screening tools What screening approaches work? What do you do after you screen?

Part 3 - Screening

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To identify and promote use of appropriate mental health screening and assessment tools.

To increase primary care providers’ ability to provide more comprehensive care e.g. through use of formal screening tools

(Only 30% of pediatricians employ formal developmental screening, yet parents’ concerns are highly predictive of true problems.)

Screening in California: Medicaid program strategy 1

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Quality improvement learning in collaboration – e.g. improve identification of at-risk children

Mental health screening of parentsEstablish separate billing mechanism for

childhood mental health screenings.

Screening in California: Medicaid program strategy 2

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o Identifying children for assessmento Identifying areas of needo Developing individualized interventions or

serviceso Evaluating progress

Use of Screening Tools

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o Fits constructs of interesto Psychometrics are acceptableo Fits children and families in programo Administration and scoring requirements

fit program staff and resources

Selecting a Tool

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o Early childhood social and emotional health

o Factors that can adversely affect emotional healthoParental mental illness or substance abuseoDomestic violenceoUnstable, unsafe or absent homeoInadequate or absent supervisiono Inadequate or poor parenting skills

Constructs of Interest

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Development - ASQ, PEDS, MCHAT Symptoms of possible social-emotional

problems - MHST, ASQ -SE Maternal Depression - Edinburgh Parent Stress - Parent Stress Index (Short

form) (PSI-SF)

What screening tools?

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Assessment Referral Provide parental support

What do you do after you screen?

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What is being “assessed?”“….the strange behavior of children in

strange situations with strange adults for the briefest possible periods of time.” (Bronfenbrenner 1979).

ORThe adaptations of a developing child in

his developing interpersonal context.

Assessment 1 - What?

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The person requesting the assessment wants the answer to a question. e.g.: 1. Should the child be removed from his home?2. Can the child attend regular school/preschool? 3. Why does the child have X behavior? 4. Can/should parent behavior change?5. Does the child need medication?

The Assessment may answer the wrong question.

Assessment 3 - For Whom?

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Behavioral, Emotional-Social & Developmental Screening and Treatment in Pediatric Primary Care

Funded by Commonwealth Fund, administered by NASHPGoals: 1- Pilot screening in 2 managed care MediCal Plans 2- Matrix of responsibilities for service 3- Inform policy changeLesson Learned: ScreeningScreening well received by parents and providers:

increased efficiency and identified children in need of services

BEST-PCP

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*For more information on: ABCD Initiative, go to : http://www.nashp.org/_catdisp_page.cfm?LID=2A78988D-5310-11D6-BCF000A0CC558925

**ABCD II project, BEST-PCP, go to: http://www.nashp.org/_docdisp_page.cfm?LID=C9C5006C-F477-499B-902ACBDB9CC70B6B

Resources & reports

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ACCOMPLISHMENTS

Initiated/expanded MH services for children 0-5 and their families in the 8 participating pilot counties

Developed infrastructure, screening and assessment, and billing and funding sources - esp use of DC 0-3 crosswalk

The Infant Preschool Family Mental Health Initiative (IPFMHI)

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Expanded knowledge of infant and preschool MH, and of relationship-based services through 200 trainings statewide

Expanded mental health provider capacity via training, consultation and supervision of mental health clinicians.

Strengthened interagency collaboration

IPFMHI ACCOMPLISHMENTS 2

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Executive summary at: www.dmh.ca.gov/CFPP/infant_preschool.asp

West Ed website: Reports of project (www.wested.org/cs/cpei/print/docs/215),

CIMH website: Resources for Screening Triage and Referral (www.cimh.org)

Knapp, Ammen, Arstein-Kersake, Poulsen & Mastergeorge: JAACAP 46(2) 152-161, 2007

Reports of IPFMHI work

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DC 0-3 to DSM-IV crosswalk allowed billing EPSDT for services in a specialty mental health system.

Feasibility of using new screening and intervention approaches.

Number of children 0-5 served increase by 51% in pilot counties over 3 years

Interagency service coordination extensive - average of 4 agencies per family.

Implications for Services

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Current: Screening used to define eligibility; tools selected to identify a particular problem (e.g. developmental delay)

Goal: Screening used to identify the child’s strengths and needs in order to plan for him.

This requires communication among agencies

Coordinating Services - the Screen Door

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DC 0-3 to DSM-IV crosswalk allowed billing EPSDT for services in a specialty mental health system.

Feasibility of using new screening and intervention approaches.

Number of children 0-5 served increase by 51% in pilot counties over 3 years

Interagency service coordination extensive - average of 4 agencies per family.

Mental Health services - lessons from IPFMHI

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Surprising: • Very low numbers for (front-end) screening

and diagnostic services.• Disparity in services to SED and Danger-to-

Self populationsOf concern:• Shelter/homeless pop’n low• Immigrant pop’n low

Coordinating services - lessons from Best PCP

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Five (of 9) priority populations are Infants and very young children with risk factors (focus is on

supporting positive relationships with parents/caregivers and support for child care providers)

Children and youth at risk of entering or in the foster care system

Children, youth, and their families that are homeless Children and youth whose parents/caregivers have or are at

risk for mental illness Children and youth who are survivors of trauma

MHSA P/EI Proposed Priority Populations

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Thank you