infant mental health: a lynchpin service in early childhood ...

1. Carlynn Nichols, D-WCCMHA Director Children’s Services Joan M. Abbey, Research Director College of Health and Human Services Eastern Michigan University Infant Mental Health: A Lynchpin Service in Early Childhood Systems of Care(Final Results from the Statewide Evaluation)MACMHB Winter Conference 2011

3. 1968 - Selma Fraiberg at Child Development Project, University of Michigan developed/tested relationship-focused home visiting for blind infants. 1973 to 1976 – Model refined & Michigan community mental health staff trained. 1989 - IMH Manual developed - refined in 2002.

4. IMHS Policy & Funding 2009 - Department of Community Health (MDCH) Medicaid policy: IMH required home-based service, Mandatory Michigan Association for Infant Mental Health (MI-AIMH) endorsement, Pre/post assessments specified. Funding MI Child, some General Fund, primarily Medicaid Home-based Services for babies/young children & parents, another option is Medicaid Prevention Services.

5. IMHS Theory of Change Assumptions/activities empirically-based. Model’s theoretical base: attachment theory (Bowlby, 1969), human ecology (Brofenbrenner, 1979), self-efficacy theory (Bandura, 1977). Focus on relationship-based home visitation. Studies show relationship-based home visitation intervention results in more secure, autonomous and task oriented children, & mothers who were more responsive to their child’s needs.

6. IMHS Theory of Change Continued Impacts individual & familial risk factors for abuse/neglect, serious emotional disturbance & delinquency: Poverty Social isolation Parental mental illness Substance disorders Low functioning parents Lack of parent-child attachment Intergenerational violence The IMH Theory of Change impacts individual and familial risk factors for babies – for example poverty, social isolation, parental mental illness and/or substance disorders, low functioning parents, lack of parent-child attachment, intergenerational violence – that place children at-risk of child abuse/neglect, serious emotional disturbance and delinquency (Chan, et. Al, 2004 Thomas, et. Al., 2002, Fanzia & Siegfried, 1998.The IMH Theory of Change impacts individual and familial risk factors for babies – for example poverty, social isolation, parental mental illness and/or substance disorders, low functioning parents, lack of parent-child attachment, intergenerational violence – that place children at-risk of child abuse/neglect, serious emotional disturbance and delinquency (Chan, et. Al, 2004 Thomas, et. Al., 2002, Fanzia & Siegfried, 1998.

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8. IMHS: Components Concrete Assistance Advocacy & Teaching Advocacy Skills Emotional Support Developmental Guidance Relationship Assistance Infant-Parent Psychotherapy

9. THE EVALUATION

10. IMHS Evaluation Funding & Purpose 2004 – 2005 Evaluation planning Rollin M. Gerstacker Foundation. 2006 - 2009 Process, outcome, & cost studies funded by US Department of Justice, Office of Juvenile Justice & Delinquency Prevention. 2007 - 2009 Evaluation of all Wayne programs funded by Detroit-Wayne County Community Mental Health Agency. Evaluation designed to assess IMHS’ efficacy in preventing child abuse/neglect & mitigating early risk factors.

11. NOT FOR CITATION

13. Evaluation Eligibility Criteria First or subsequent pregnancy/birth or adoption from prenatal through 36 months. Child must live with adoptive, permanent legal guardian or bio-parent. Family/child must not have any of the following: Have primary service modality as group services (i.e. parent/child play groups) Be medically fragile Be so severely impaired/delayed that the ASQ-SE cannot be administered (i.e. autism) Be in foster care

14. Evaluation Instrumentation & Data Sources Staff Characteristics Survey Fidelity Case Vignette Supervision Logs Services Provided Checklist Consumer Satisfaction Survey Objectives Problems Checklist (OPC) Ages and Stages Questionnaire-Social Emotional (ASEQ-SE) Goal Achievement Maintenance (GAM) Modified Family Inventory of Life Events (FILE) Process Study Outcome Study

15. IMH Process Evaluation Questions – System Level Does IMH capacity increase? Does IMH quality improve? 8 programs in 2008, 3 in 2005. ACC, DCI, SWS, NEGC, CC, TGC, LBS, SFS. 28 staff in 2007 – 58 currently active. 26 stakeholder interviews (response rate 54%). Two-thirds were IMH referral sources.

16. System Level Results Continued Stakeholders report access to IMH especially for foster care children, better referral system, more capacity, & more training. 80% know whom to refer to IMH services & what are IMH service components. Two-thirds report Significant to Moderate changes in families receiving IMH services.

17. Stakeholders’ Take on Capacity & Quality Outcomes

18. “I think IMH services are critical to helping strengthen & support parent-child relationships that are in stress or at risk. It ultimately may prevent neglect/abuse, or out of home placement.” “The families we serve are high risk, & often have not learned from their parents how to appropriately interact with their children. Their past experiences are often a barrier to bonding with their children and IMH can help.”

19. IMH Services Referral Sources

20. Process Evaluation Questions Program Level Questions Is there fidelity to the IMH model? What are the characteristics of IMH staff? What are the scope, duration & intensity of service delivery? Individual Level Questions What are the characteristics of the families receiving services?

22. Process Results IMH Fidelity Vignette Results 11 agencies 73 completed vignettes 57.5% high fidelity 41.1% moderate 1.4% low fidelity No MI-AIMH endorsed staff scored low fidelity 5.2 hours average monthly supervision Staff Characteristics (N=130) Age range 22-64 years (average - 38) 98% Masters degree Years in field average - 5.24 Ethnicity: 69% Caucasian 18% African American 6.2% Latino 3.9% Middle Eastern

23. Duration of Services

24. Consumer Satisfaction

25. Parent Characteristics (N=432) All but 8 - birth parents – All but 11- Female Average age 25 44.8% Caucasian, 37.4% African-American, 10.2% Hispanic 65.7% never married 88.6% high school education or less 20.2% pregnant at intake 63.4% have DSM-IV diagnosis One third (70 cases)low functioning or developmentally disabled

26. What are the characteristics of families served by IMH programs? Average age of caregivers is 25, range from 14 (n=2) to 60 (n=1). Ten males as primary caregivers, (2 - completers). 57.3% child is second/subsequent pregnancy, birth or adoption. 113 caregiver mental health status recorded: 44.2% depression/depressive disorders, 16.8% bi-polar. 17% low functioning or developmentally disabled.

27. Family Characteristics 49% African American, 31% White, 12% Hispanic, 8% Multi-racial. Two-thirds never married, 22.8% married, 11.1% divorced. Three-quarters live with another adult (71%), most often: primary caregiver’s parent(s) (35.9%), spouse/partner (29.3%). 43% < a high school diploma, 34.6% high school diploma, 10.7% GED, 7.6% Associates degree, 4.2% Bachelors degree.

29. Income at Intake & Termination

30. Infant/Toddler Characteristics (N=389) 49.9% Male; 50.1% Female 39.5% first child; 70.5% second+ child Mean age:1.5 years 35.1% Caucasian; 33.6% African-American; 10.5% Hispanic;18% Bi-racial

31. Infant/Toddler Presenting Issues

32. Outcome Evaluation Research Questions Does participation in IMH services: Improve parental mental health status? Promote attachment by increasing parents’ age appropriate expectations/interactions with infants/toddlers? Promote age appropriate social emotional development in infants/toddlers? Reduce child abuse and neglect? Reduce health care costs?

33. Family Status at Closure

34. Research on Factors Affecting Attrition Waitlisted consumers are more likely to drop out. Completion more likely when: Home visitor received more hours of direct supervision. Staff built positive, predictable relationship with family. Staff were persistent but flexible in following through with program elements. Staff provided strong support & understanding for caregivers.

35. Outcome Evaluation – Objectives, Problems Checklist (OPC) Results

36. Objectives Problems Checklist Results Paired Sample T-tests significance between Intake &Termination scores on all OPC scales for Completers at p .001 level & clinical significance. Non-completers higher Intake OPC scores than Completers.

37. OPC Total Score at Intake vs. Closure

38. Changes in Parent’s Mental Health Status 56.1% (32) had a DSM-IV diagnosis at intake. 35.2% (20) had diagnosis at case closure.

39. Age Appropriate Expectations of Child

40. Infants/Toddlers Age Appropriate Social-Emotional Development ASQ-SE results: Mean differences in change scores move in the direction of positive change & with each successive administration, the gains are greater for all children. Younger children gains strongest.

41. Reduce Child Abuse and Neglect FILE: Physical abuse/violence in home fell from 17% to 9%. Child Protective Services registry checks: 71 closed families gave permission for checks. Registry checks conducted up to 43 months post-intake (mode 24 months). Prior to IMH services - 32 investigations & 14 substantiations. During/after IMH services - 13 investigations, (3 investigations were on completers); NONE of the 13 investigations were substantiated.

42. Reductions in Health Care Costs 81.9% of caregivers No additional pregnancies Emergency room use in past four months: At intake,15 families At closure, 10 families Immunizations up-to-date: At intake, 71% At closure, 83% Unwanted or difficult pregnancy: 12 months before or during service, 31% 12 months post service, 19.4%

43. COST ANALYSIS

44. Group One (n=35); families where infant/toddler was first pregnancy/birth. Group Two (n=47); families where infant/toddler was second or subsequent pregnancy/birth. Comparative analyses conducted to determine if IMHS received differently by families based on target child birth order. Analyses failed to show a relationship between birth status & termination status. Likelihood of successful program completion slightly higher for 1st time parents 42.9% vs. 46.8% for second/subsequent child.

45. Cost Study – Distributive Efficiency What is the maximum & minimum dosage of IMH services needed to achieve desired outcomes for Sample 1 (first births)? What is the maximum & minimum dosage of IMH services needed to achieve desired outcome for Sample 2 (second births)?

46. Does the maximum & minimum dosage of IMHS needed to achieve desired outcomes for the IMH service populations vary by presenting issues? Number of successful completing infants/toddler with presenting issues & caregivers diagnosis insufficient for statistical analysis between presenting issue & length of time to program completion. Descriptive analysis provides some insight-CPS cases, failure to thrive cases, depression & ADD shorter average length of time to successful program completion.

48. Evaluation Impact - Fidelity 1st year (2007) found low to moderate fidelity relative to use of reflective supervision & understanding of parallel process in supervision by IMH therapists & supervisors. In 2008 MI-AIMH revised training to place greater emphasis on this topic & held a program supervisors retreat focused on parallel process. 2009-2010 fidelity vignettes with new staff found fidelity increased from moderate to high.

49. Questions