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

1. No Wrong Door for Early Childhood Intervention: Is there a screen? CAPTA Summit Penny Knapp MD Medical Director, CA DMH 1/23/08

2. Topics for today • 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

3. Part 1 Children in the CWS system • 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)

4. What does this mean for the young child? • Attachment disrupted • Neglect or trauma early in life • Loss of safe context • Developmental risk • Risk of social-emotional disorders

5. The critical importance of attachment

6. Trauma Child is overwhelmed and may: • Dissociate • Be hypervigilant (+/or “hyperactive” • Have disturbed sleep, appetite, concentration DC 0-3 diagnostic criteria

7. Can we diagnose mental disorders in children 0-3? The Diagnostic Classification for Children Zero to Three. www.zerotothree.org A 5-Axis diagnostic system, parallel to the DSM-IV except for Axis 2 AXIS 1 - Psychiatric disorder Axis 2 - Relationships (In DSM-IV, Personality Disorder) Axis 3 - Medical Axis 4 - Psychosocial stress, Axis 5 - PIR-GAS

8. What are the stakes - for the child? 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)

9. Regulatory Disorders (DC 0-3) Dx requires both a distinct behavioral pattern and a sensory, sensory-motor, or organizational processing difficulty. Type 1 Hypersensitive Type II Under reactive Type III Motorically Disorganized, Impulsive Type IV Other Regulatory disorders underlie many or most psychiatric diagnoses in children

10. 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.

11. Maternal depression - impact on the child Children of depressed mothers have • Behavioral problems, • Emotional problems, • Problems with their own relationships later in life.

12. How do CWS children fare, developmentally? • 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.

13. How many get referred for Early Intervention? • 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)

14. Part 2 - Evidence re. the effectiveness of early intervention Brief review of evidence • Published evidence of efficacy of programs Successful applications in California • IPFMHI • Best PCP (ABCD II) • CIMH development teams for EBPs

15. Examples of successful prevention programs (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

16. Recent State Initiatives • 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

17. Current CA activities 1 Early Mental Health Initiative (EMHI) - At-risk children K - 3. Run by DMH - legislative appropriation • CIMH Development teams to implement evidence-based practices www.cimh.org 3 ABCD Screening Academy All are successfully using standardized screening tools

18. ABCD Screening Academy • 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

19. Current CA activities, cont. 4 ABC - Assuring Better Connections LACDMH 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

20. Current CA activities, cont. 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

21. Recent & current initiatives -National • 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

22. Part 3 - Screening • Medicaid Program Strategy • Use of Screening tools • What screening approaches work? • What do you do after you screen?

23. Screening in California: Medicaid program strategy 1 • 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.)

24. Screening in California: Medicaid program strategy 2 • Quality improvement learning in collaboration – e.g. improve identification of at-risk children • Mental health screening of parents • Establish separate billing mechanism for childhood mental health screenings.

25. Use of Screening Tools • Identifying children for assessment • Identifying areas of need • Developing individualized interventions or services • Evaluating progress

26. Selecting a Tool • Fits constructs of interest • Psychometrics are acceptable • Fits children and families in program • Administration and scoring requirements fit program staff and resources

27. Constructs of Interest • Early childhood social and emotional health • Factors that can adversely affect emotional health • Parental mental illness or substance abuse • Domestic violence • Unstable, unsafe or absent home • Inadequate or absent supervision • Inadequate or poor parenting skills

28. What screening tools? • 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)

29. What do you do after you screen? • Assessment • Referral • Provide parental support

30. Assessment 1 - What? What is being “assessed?” “….the strange behavior of children in strange situations with strange adults for the briefest possible periods of time.” (Bronfenbrenner 1979). OR The adaptations of a developing child in his developing interpersonal context.

31. Assessment 3 - For Whom? The person requesting the assessment wants the answer to a question. e.g.: • Should the child be removed from his home? • Can the child attend regular school/preschool? • Why does the child have X behavior? • Can/should parent behavior change? • Does the child need medication? The Assessment may answer the wrong question.

32. BEST-PCP Behavioral, Emotional-Social & Developmental Screening and Treatment in Pediatric Primary Care Funded by Commonwealth Fund, administered by NASHP Goals: • 1- Pilot screening in 2 managed care MediCal Plans • 2- Matrix of responsibilities for service • 3- Inform policy change Lesson Learned: Screening Screening well received by parents and providers: increased efficiency and identified children in need of services

33. Resources & reports • *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

34. The Infant Preschool Family Mental Health Initiative (IPFMHI) 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

35. IPFMHIACCOMPLISHMENTS2 • 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

36. Reports of IPFMHI work 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

37. Implications for Services • 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.

38. Coordinating Services - the Screen Door 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

39. Mental Health services - lessons from IPFMHI • 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.

40. Coordinating services - lessons from Best PCP Surprising: • Very low numbers for (front-end) screening and diagnostic services. • Disparity in services to SED and Danger-to-Self populations Of concern: • Shelter/homeless pop’n low • Immigrant pop’n low

41. MHSA P/EI Proposed Priority Populations 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

42. Thank you