Addressing Infant/Toddler Mental Health in Tennessee

1. Addressing Infant/Toddler Mental Health in Tennessee Frances Duran National Technical Assistance Center for Children’s Mental Health Georgetown University Center for Child & Human Development September 26, 2011

2. For Discussion Today… • Why is early childhood mental health important? • How can we fund services and supports for infants and toddlers? • How can we build workforce capacity in this area?

3. Why is Early Childhood Mental Health Important?

4. Early childhood mental health is a young child’s ability to… • LAUGH • LOVE • LEARN (In the words of renowned infant psychologist Alicia Lieberman)

5. Estimated Prevalence • Between 4 and 10% of all young children have clinically significant emotional and behavioral challenges (Center for Mental Health in Schools, 2005) • Children who are poor are much more likely to develop behavior problems with prevalence rates approaching 30% (Qi & Kaiser, 2003)

6. Societal Benefits of Intervening EARLY • Reduced use of special education • Increased high school graduation & college attendance rates • Reduced use of welfare • Reduced crime and contact with criminal justice system (Karoly, Kilburn & Cannon, 2005)

7. Benefit-Cost Ratios: Examples • Nurse Family Partnership: 5.7 ($41,419 / $7,271) • Home visiting for low-income first-time mothers • Focuses on improving pregnancy outcomes, mother’s self-efficacy, and parenting skills • Prenatal to age 2 (Karoly, Kilburn & Cannon, 2005) • Parent Child Interaction Therapy: 3.6 ($4,724 / $1,296) • Live coaching format (therapist to parent) • Focuses on improving parenting interaction and helping child develop a secure attachment to the parent(s) • Ages 2 to 8 (Aos, Lieb, Mayfield, Miller & Pennucci, 2004)

8. How do we foster positive early childhood mental health? • Promote the behavioral/emotional well-being of all • Strengthen the well-being of children and families at risk • Ensure access to services for those with atypical development • Help families address their own barriers • Expand competencies of non-familial caregivers (e.g., child care providers) Jane Knitzer

9. Assessments for Infants and Toddlers • Issues: • Reluctance to refer children so young • Impact of environmental/family issues on infants/toddlers overlooked > missed opportunity for assessment • Diagnostic Tool: DC: 0-3R (Zero to Three) • Provider Reimbursement: Crosswalk to DSM:IV and/or ICD:9-CM • Resources • “Developing a DC:0-3R Crosswalk” and “DC:0-3R: Crosswalk Development and Use in Professional Development and Reimbursement” Available at: www.zerotothree.org • Example: Florida’s CrosswalkAvailable at: www.thefloridacenter.org/pdfs/Fl_Crosswalk_June_2010.pdf

10. Interventions forInfants and Toddlers • Issues • Dyadic nature of the work can be hard to fund • Reluctance by some to diagnose infants/toddlers • Few evidence-based practices for this age group • Lack of providers trained in infant/early childhood mental health

11. Provider Reimbursement for Infant/Toddler Interventions • General Strategies: • Braid/pool funding • Maximize Medicaid (seeking policy/regulatory changes as needed) • Resources: • Matrix of Early Childhood Mental Health Services and Supports in Social and Emotional Health in Early Childhood (Perry, Kaufmann & Knitzer, 2007) • Early Childhood Mental Health Services: Financing Map

13. Provider Reimbursement for Infant/Toddler Interventions • Example 1: • Funding Source: Medicaid/EPSDT • Process: Draw down funds by identifying a diagnosis using the DC:0-3R that is billable through EPSDT(e.g., supports “medically necessary”) Under EPSDT, state Medicaid programs must cover "necessary health care, diagnostic services, treatment and other measures...to correct or ameliorate defects and physical and mental illnesses and conditions." 42 U.S.C. § 1396d(r)(5) Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening-even if the condition cannot be prevented or cured.

14. Provider Reimbursement for Infant/Toddler Interventions • Example 2: • Funding Sources: Medicaid, county funds, United Way, private foundations • Process: secure a diagnosis through DC:0-3R then bill through Medicaid; if child does not have a diagnosis, then county or private funds are used • Note: state’s Medicaid plan includes provision that you can bill Medicaid in the child’s name, even if the services are provided to the parent - exclusively or jointly

15. Building a Provider Workforce with I/ECMH Expertise • DC:0-3R • Train-the-trainer model • Identify evidence-based and promising practices that “fit” for your community • Learning Collaborative model • Resource: “The Learning Collaborative Model.” Available at: www.chdi.org/download.php?id=428 • Resource: Scan of Early Childhood EBPs. Available at: http://gucchdtacenter.georgetown.edu/early_childhood_SOC.html

16. Building a Provider Workforce with I/ECMH Expertise (cont’d) • Standardize Personnel Competencies • Resource: “California Training Guidelines and Personnel Competencies for Infant-Family & Early Childhood Mental Health.” Available at: www.ecmhtraining-ca.org/guidelines.html • Pre-service Training/Education • Partnering with higher education • Funding for Capacity-Building Efforts • Partner with TN Early Connections/System of Care

17. Going Forward: Questions to Consider • How will you increase the number of providers trained to use the DC:0-3R? • Will you pursue a crosswalk between DC:0-3R and the ICD:9-CM? • What evidence-based/promising practices for infants/toddlers will you pursue and how will you train the provider community on these EBPs? • How will you create provider interest in trainings on the DC:0-3R and new EBPs and address provider turnover? • What reimbursement options are available to you through your state’s Medicaid Plan? • What other funding streams might be of assistance?

18. Resources Financing • Effective Strategies to Finance a Broad Array of Services and Supports (Louis de la Parte Florida Mental Health Institute, 2007) http://rtckids.fmhi.usf.edu/rtcpubs/hctrking/pubs/briefs/RTCstudy3IBrief01.pdf • Social and Emotional Health in Early Childhood (Perry, Kaufmann & Knitzer, 2007) • “Strategic Financing of Early Childhood Mental Health Services” • “Spending Smarter: A Funding Guide for Policy Makers and Advocates to Promote Social-Emotional Health and School Readiness” • Matrix of Early Childhood Mental Health Services and Supports • Funding Early Childhood Services and Supports (Wishman, Kates & Kaufmann, 2001). Available at: http://gucchd.georgetown.edu/72441.html • Federal Funding for Early Childhood Supports and Services: A Guide to Sources and Strategies (The Finance Project, 2000). Available at: http://www.financeproject.org/publications/fedfund.pdf

19. Resources Financing (cont’d) • Making Dollars Follow Sense:Financing Early Childhood Mental Health Services to Promote Healthy Social and Emotional Development in Young Children (National Center for Children in Poverty, August 2002). Available at: http://www.nccp.org/publications/pub_483.html • Maximizing the Use of EPSDT to Improve the Health and Development of Young Children (National Center for Children in Poverty, June 2006). Available at: http://www.nccp.org/publications/pub_665.html • A Self Assessment and Planning Guide: Developing a Comprehensive Financing Plan (Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, 2006). Available at: http://www.tapartnership.org/SOC/SOCfinancingResources.php

20. Resources Workforce Development • “Developing the Work Force for an Infant and Early Childhood Mental Health System of Care” in Social and Emotional Health in Early Childhood (Perry, Kaufmann, & Knitzer, 2007) Services and Supports • Supporting Infants and Toddlers with Challenging Behavior. Available at: www.challengingbehavior.org/do/resources/documents/rph_supportInfantsToddlers.pdf • Being an Evidence-Based Practitioner. Available at: www.challengingbehavior.org/do/resources/documents/rph_practitioner.pdf • Early childhood mental health consultation – multiple publications (http://gucchd.georgetown.edu)

21. Resources Websites • Georgetown University National Technical Assistance Center for Children’s Mental Health http://gucchd.georgetown.edu • Technical Assistance Partnership for Child and Family Mental Health www.tapartnership.org • Center on the Social and Emotional Foundations for Early Learning www.vanderbilt.edu/csefel/ • ZERO TO THREE http://zerotothree.org • Technical Assistance Center on Social Emotional Intervention for Young Children www.challengingbehavior.org

22. References • Aos, S, Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia: Washington State Institute for Public Policy. • Center for Mental Health in Schools at UCLA (2005). Youngsters’ mental health in schools and psychosocial problems: Where are the data? Los Angeles, CA: Author. • Karoly, L.A., Kilburn, M.R., & Cannon, J.S. (2005). Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, CA: RAND Corporation. • Qi, C. H., & Kaiser, A. P. (2003). Behavior problems of preschool children from low-income families: Review of the literature. Topics in Early Childhood Special Education, 23, 188-216.

23. For More Information Frances Duran National Technical Assistance Center for Children’s Mental Health Georgetown University bazazf@georgetown.edu