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Volume 27, Issue 473 |
August 7, 2006 |
CHILDREN’S MENTAL HEALTH: STATES REACH OUT TO THE YOUNGEST PATIENTS
Jennifer Stedron
Eleven-year-old "Mia's" suicide threat was shocking, despite her increasing moodiness and acting out in school. Like many parents, her mother could trace the start of her problems back to toddlerhood; even at 18 months her violent mood swings had made her a "difficult" child. With the situation now so dire, her mother agonized: could Mia's serious depression have been prevented if she had received professional help in her early years?
According to a growing mound of research, the answer is: yes. Research suggests that early concerns, such as withdrawal or sleeplessness, can be predictors of later mental health problems. And early intervention for those concerns, such as parent-infant therapy, may ward off later depression or developmental delays—which can improve school readiness and academic success, in addition to overall child (and later, adult) well-being.
In an effort to prevent mental health problems, some states are launching innovative programs. In Vermont, the Children's Upstream Services Initiative (CUPS) garnered national attention after research showed that it had significantly reduced parents’ stress and improved the developmental health of children. Wisconsin's Think Big, Start Small program is designed to increase public awareness of early childhood issues, including infant mental health. And a pilot program in Massachusetts promotes identification of and intervention services for at-risk children.
But finding resources for programs whose payoff is not immediate can be difficult, especially when other programs are competing for funds. Says Vermont Sen. Jim Leddy, who headed a community mental-health center for 20 years, prevention programs are "the last to be funded and the first to be cut."
Environmental Stressors
Good infant mental health development can be disturbed by factors such as the child's physical environment (i.e. lead exposure) and stressors including abuse, neglect, maternal depression and exposure to violence. Research now links excessive stress during early childhood to disruptions in brain architecture and an increased probability of developmental delays.
Around 8 percent of preschoolers have diagnosed mental disorders, but many more are at risk. One recent study found that 10 percent of mothers have depression or anxiety disorders—which can harm a child’s mental health. Additionally, more than 39,000 infants annually are placed in foster care and of those children, between 40 percent and 85 percent will have mental health disorders.
In an effort to address this issue, in 1986 Congress passed Part C of the Individuals with Disabilities Education Act (IDEA). A grant program, Part C was created to support early intervention services for children 0-3 years who have a "diagnosed physical or mental condition" that has a high probability of resulting in social, emotional and other delays. Currently all states and eligible territories have Part C programs, which provide qualifying children and their families with services including parent support groups and family counseling. It is up to states to define who is eligible. Some states have expanded access by broadening eligibility criteria from traditional diagnoses such as depression, to environmental stressors such as recurrent family violence.
Even so, several problems impede treatment, including:
- difficulty in identifying the children who need help;
- a lack of available service providers;
- inconsistent diagnostic standards; and
- failure by some Medicaid programs to reimburse for prevention and treatment of disorders in infants and toddlers.
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program was designed in part to ensure that all children under age 21 receive mental health services. However, the federal requirement that services be "medically necessary" may be narrowly interpreted by states (and providers) as applying only to those with serious emotional disturbances, and not to the wider group of children who are at risk and in need of preventive care. States have great leeway in defining what constitutes a developmental assessment or screen, and some have adopted broad definitions. But providers may not be aware of those definitions, and thus keep diagnosis and treatment limited.
Vermont Expands Services
Some of those factors were initial complications for Vermont's CUPS program, which was formed in 1997 to expand mental health services and increase interagency coordination of services for young children with severe emotional disturbances and their families. The name “Children’s UPstream Services” was taken from the adage about people rescuing children one by one from a river until someone wisely goes upstream to prevent children from falling into the river in the first place.
Initially funded by a $5.7 million, five-year grant from the federal Center for Mental Health Services, CUPS provides case management, consultation for child-care and direct-service providers, training across agencies and parent peer support. The program has garnered such respect that when the federal grant ended, replacement state funds were allocated without a fight.
As CUPS was implemented, a dispute arose over reimbursement for diagnoses and treatment. Mental health professionals wanted to “code” bills using the first comprehensive guide for disorders in infants and toddlers: the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3R). Few states accept DC: 0-3R codes for Medicaid reimbursement, preferring the "bible" of mental health diagnosis for adults and children, the DSM-IV.
On the opposite side, many child-care providers—wary of the negative effects of "labeling"—were reluctant to have young children receive diagnoses of mental health problems. Ultimately, both child-care providers and mental health professionals agreed to use a general code from the DSM-IV that identifies parent-child relationship difficulties, and the code was approved for Medicaid reimbursement. While this has resolved the primary goal of serving children and families, other problems remain, said Brenda Bean, director of Vermont's Early Childhood Mental Health Programs. For example, like officials in many other states, providers don’t know the prevalence of certain disorders in the state’s youngest children, which impairs their ability to provide help.
Wisconsin Raises Awareness
Wisconsin has a comprehensive statewide plan for infant and early childhood mental health services. And in 2001, it launched “Think Big, Start Small,” a public awareness campaign initiated by collaborating state agencies, child-care organizations, educational agencies and others. At least $750,000 in public and private funds were spent on the campaign in 2004, according to Carol Maurer, state campaign coordinator. To educate parents and other care-givers, agencies distribute the "Quality Early Relationships MATTER" brochure. And the training of child-care providers has become a priority. "We train at least 5,000 child-care providers a year and incorporate social/emotional development in our trainings," said Maurer.
In November 2001, Massachusetts established the Massachusetts Early Childhood Linkage Initiative (MECLI), which promotes collaboration between child welfare and Part C (of IDEA) early intervention services. Funded by federal and state dollars, private insurance and sliding-scale parent fees, this first-of-its-kind program was tested in three pilot sites. All children under 3 years who were named in a newly opened abuse or neglect case in those pilot sites were referred to Part C services. Researchers found that 74 percent of these children were eligible for early intervention services such as home-based counseling, and 49 percent had developmental delays.
John Lippitt, director of MECLI, said the program challenges included parental buy-in: approximately 27 percent of families refused initial referrals and of those that accepted, another quarter didn't respond to attempts to schedule an assessment. “[S]uccess in implementing these referrals…will not be easy, even if the child welfare and Part C systems are supportive and costs are not an issue," Lippitt said. Overall, however, the pilot program (which ended in December 2005) was deemed a success and many non-pilot sites adopted the referral procedure even without a statewide mandate to do so. The state is still fine-tuning the policies and procedures for statewide implementation, which is expected to occur within the coming year.
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