Spark NH: Infant mental health screening Kristen Lynch • Laura Marden Moore Courtney Marrs • Debra Samaha

Objectives Project goals & Spark NH Introduction Barriers Recommendations New Hampshire Other states Conclusion of findings

Project Overview Research the delivery of socio-emotional/ mental health services to children less than nine years. Assess barriers to screening, assessment, and treatment. Medicaid billing mechanisms Access to providers and services Conduct key informant interviews and share feedback SPARK NH asked us to….

Spark NH Mission To provide leadership that promotes a comprehensive, coordinated, sustainable early childhood system that achieves positive outcomes for young children and families, investing in a solid future for the Granite state.

Introduction

Definition Infant Early Childhood Mental Health (I-ECMH) Developing the capacity of an infant/young child to: Experience, regulate, and express emotion Demonstrate developmentally appropriate behavior Develop and sustain stable relationships Explore the environment and learn What is meant by infant? There is no universal acceptance of the age range that IMH includes. The term “Infant” in a clinical setting means a child that is under 1 year old, but for the purposes of the field of IMH, the definition changes depending on the organization. Through our literature search, it seems that the most widely accepted age range is 0-5, however 0-3 is common and in some cases, up to 0-9. More recently, the term “Infant mental health” is expanding to include the term “early childhood” and may be written as I-ECMH.

Why is I-ECMH so Important? 5 Numbers to Remember 700 18 90-100 700 per second 18 Months 90-100 % 3:1 4-9 I-ECMH is synonymous with healthy social and emotional development…Research has shown that supporting healthy emotional development is as crucial as teaching a child to speak or take his/her first steps. By 9 months old babies' strengths, adaptive responses, and their potential vulnerabilities have been shaped. Babies' brains are like plastic - moldable and impressionable. It is crucial that parents develop appropriate care-giving strategies and create positive influences to enhance their earliest relationship with their child. 700 Genes provide the basic blueprint, but experiences are what shape the process that determines whether or not a child’s brain will provide a strong or weak foundation for all future learning, behavior, and health. In early life these experiences, whether good or bad, create 700 new neural connections every second through the brain which get stronger through repeated behavior and become the building blocks for all future development. 18 The experiences and environments that children are exposed to in their early years can have lasting impact on later success in school and life. The barriers to a child’s educational achievement start early… and compound without intervention. Differences in the size of children’s vocabulary first appear at around 18 months of age. Research as shown that by age 3, children raised by college-educated parents or primary caregivers had vocabularies 2 to 3 times larger than those whose parents had not completed high school. This obviously affects a child by the time they attend school because they’re already behind their peers unless they’re engaged in a language-rich environment early in life. 90-100 Significant adversity impairs development in the first three years of life – and the more adversity a child faces, the greater the odds of a developmental delay. Risk factors such as poverty, mental illness that a caregiver may have, child maltreatment, single parent, and low material education all have a cumulative impact. Children exposed to as many as 6 risk factors face a 90-100% likelihood of having one or more delays in their cognitive, language, or emotional development. 3:1 Early experiences actually get into the body, with lifelong effects – not just on cognitive and emotional development, but on long term physical health as well. A growing body of evidence now links significant adversity in childhood to increased risk of a range of adult health problems, including diabetes, hypertension, stroke, obesity, and some forms of cancer. Children who experience an adverse event are 3 times more likely to have a health problem as an adult. 4-9 And last but not least, we all want to know the economic benefits! Providing young children with a healthy environment in which to learn and grow is not only good for their development – economists have also shown that high-quality early childhood programs provide huge returns on investment to the public. Research has shown that for every dollar invested in early learning programs, 4-9 dollars are claimed in return. Increased earnings were in returns in the form of reduced special education, welfare, and crime costs, and increased tax revenue. 4-9 Dollars 3:1 Odds

5 Numbers to Remember Take Home Messages Getting things right the first time is easier and more effective than trying to fix them later Early childhood matters because experiences early in life can have a lasting impact on later learning, behavior and health. Highly specialized interventions are needed as early as possible for children experiencing toxic stress Early life experiences actually get under the skin and into the body, with lifelong effects on adult physical and mental health. All of society benefits from investments in early childhood programs.

Barriers

Barriers for I-ECMH Definition of I-ECMH Lack of awareness Access to screening Lack of investment Medicaid and private insurance

Medicaid Covers 54,800 children in NH (2010-2011) Provides a comprehensive set of benefits 0-18 Every state is required to provide screening for physical, cognitive and emotional issues for eligible children and provide treatment. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Screening for developmental delays Variable across states- only 10% meet federal benchmark of 80% screened, 50% pay for treatment if diagnosis assigned 50% pay for treatment without diagnosis 11

Private Insurance 12 Approximately 67% of NH population is utilizing coverage other than Medicaid. Private insurance companies don’t reimburse for I- ECMH screening outside of the physicians office. Community-based interventions Dyadic therapies

Distribution by Insurance Status 2010-2011 Highlight = most of the population is through private insurance! (leads to next slide) Statehealthfacts.org

Insurance and Medicaid Diagnosis Challenges 14 Provider approval to receive insurance or Medicaid payments Requires a diagnosis to provide payment Lack of: Appropriate infant-toddler diagnostic criteria Diagnostic and treatment codes that qualify for insurance reimbursement Comments from key informants: “For lack of better words, codes are babied down to try and fit the needs of young children and it simply doesn’t work.” “The use of diagnosis codes labels children.” American Psychologist February-March 2011 page 135 14

New Hampshire Behavioral Health Law Suit April 2011 – Investigation by the Dept. of Justice concluded that NH violated the American with Disabilities Act by: “failing to provide services for individuals with serious mental illness in the most integrated setting appropriate to their needs”. Advocates are hopeful that this will impact children’s mental health. NH Medicaid will not speak with us due to this suit. http://www.nhcdd.org/documents/SpringRAP2013.pdf 15

Recommendations New Hampshire Perspective

Multidisciplinary Approach “No one individual can possess the expertise to evaluate and treat all the possible mental health, relational and developmental issues that can affect a young child”. -Stakeholder Evaluate needs, resources and priorities in NH to come up with the best approach for I-ECMH. Community based interventions Use evidence based tools Watch Me Grow NH Pediatric Society initiative Project LAUNCH

Medicaid Spending Smarter Checklist 18 Spending Smarter Checklist A funding guide for policymakers and advocates to promote social and emotional health and school readiness. Report results to Spark NH and key Stakeholders Establish a sustainable cost-per-unit reimbursement rate “Medicaid needs to establish a sustainable cost-per-unit reimbursement rate. Current rate for reimbursement is very low $10, as compared to a vaccination, which is over $20.” - Stakeholder 18

I-ECMH is a Public Health Issue I-ECMH: Mental Health or Public Health Issue? NHPHA : Identify I-ECMH as a public health priority. New legislature is more receptive to work with NHPHA Focus on Prevention (i.e. screening) Develop key messages for public health audiences Topics to include: Where to find resources, the importance of I- ECMH indicators, early detection, multidisciplinary approach, and parent-child relationship. Eliminate the stigma of “mental health” Our children are our future!

Create Partnerships Partner with a community-based programs New Hampshire WIC program “Deliver assessment/screening to children at various times (start, midway and/or exiting the program) - It’s a way to partner with a program with similar goals and gives access to children 0-5 years of age” -Stakeholder

Caregiver Support Parents/Primary Caregivers Home visiting and family support programs Strengthen confidence Childcare providers and teachers Liaison between mental health and child care providers Promote awareness of I-ECMH and development “There is a lack of understanding about the importance of accessibility within child care facilities.” -Stakeholder

Workforce Development ~75% of families turn to their PCP for support Cross training opportunities Increase capacity and the level of expertise of providers Expand eligibility for “qualified providers” to perform I- ECMH screening “It is important to allow qualified staff, other than physicians, to screen and review findings with parents and caregivers. Qualified staff include those who have received training on developmental screening tools.” - Stakeholder

I-ECMH Screening Best Practices Build Initiative 2013

I-ECMH Screening: Examples of Best Practices Best practices by discipline: Primary Care - Bright Futures Assessment – Brazelton Touch Points System Treatment - Trauma Informed Care Model Caregiver support – Head Start Model ******Wouldn’t mention these unless asked what they are******** A piece of the Head Start program is that all children are screened. Bright futures – defined in next slide Brazelton - Utilizes a series of questions given points that create a score for assessing where a child marks for healthy mental health

Physician Standard of Care: Bright Futures A Barometer to gauge the state’s performance on key child health indicators. Recommended by the American Academy of Pediatrics Documented success The standard of care for Maine physicians Has been implemented in New Hampshire (Dartmouth) Implement the use of Bright Futures clinical forms at Well-child visits Bonus! Providers who complete the forms are reimbursed at an enhanced rates. To go into further detail about Bright Futures… It is ….

I-ECMH in NH Progress Medicaid reform Transforming Children’s Behavioral Health Care Plan Community Bridges Early Childhood & Family Mental Health Competency System Utilization of video interviewing/conferencing with providers September 2013 - Improvement of the credentialing system Self assessment for providers Incentive to improve skills Medicaid reform Reimbursement rates increase Allow use of DC:0-3R Must include coverage for children’s preventative care Thus far, we’ve talked a lot about barriers, challenges, and suggestions for NH to improve I-ECMH, but I want to highlight some of the progress that is ongoing… The release of Transforming Children’s Behavioral Health Care Plan for I-ECMH With the help of Community Bridges, there has been improvement in dissemination of resources and supports. The development of an Early Childhood and Family Mental Health Competency System Video conferencing provides increased opportunities for working with providers with expertise in IECMH (which is hard to come by in NH) Funding will be extended until 2019

Recommendations Other States

I-ECMH Classification DC:0-3R An age-appropriate approach for assessing infants, toddlers and preschool children. Created to complement other diagnostic and classification systems by describing symptoms, patterns, and associated events/developmental features. The DC:0-3R Crosswalk Table used in some states to address payment barriers and improve reimbursement rates Maine Florida

Adoption of DC:0-3R Crosswalks

In Summary… We have an opportunity to educate parents, caregivers, professionals, and providers. Frame as a I-ECMH as a public health issue Create a multidisciplinary approach Adopt Bright Futures as the state standard of care for NH physicians. Develop partnerships NHPHA Policy Committee Community child programs i.e WIC Connect with other states to implement crosswalk table. Mark Rains – Psychologist Vienna Mountain Consulting Kathryn Shea – President and Chief Executive Officer for FL Center for Early Childhood Inc.

Acknowledgements JoAnn Cobb- Program Director, Early Childhood and Family Support Program and President of the NH Association for Infant Mental Health Phone call interview 03/19/2013 Jane Zill, LICSW- Licensed therapist, Individual practice, Portsmouth, NH Emailed me 04/09/2013 Egon Jenson- Administrator, Children's Mental Health Services for the Department of Health and Human Services. Spoke on 04/05/2013 Jodi Lubarsky- Child Adolescent and Family Services Director, Seacoast Mental Health Center, Email interview: 04/01/2013: Laura Milliken-Director of Spark NH- Early Childhood Advisory Council- several interviews Deirdre Dunn-Early Childhood Special Projects Coordinator Maternal & Child Health Section DHHS Ellyn Scheiber- Director of Early Childhood Services, Community Bridges. Phone interview 03/12/2013 Kim Firth, Program Director, Endowment for Health Kathryn Shea- President & Chief Executive Officer, The Florida Center for Early Childhood, Inc. Geoffrey Nagle: Clinical social worker, Associate Professor of Psychiatry at the Tulane University School of Medicine and the Director of the Institute of Infant and Early Childhood Mental Health Rebecca Marrs Child and Family Therapist Riverbend Community Mental Health Sean Ellison Therapeutic Behavioral Services Riverbend Community Mental Health Key informant interview list

Acknowledgments, cont’d. Michael Rovaris-Technical Assistance, Educational Assistance Center, Waltham, MA Greg Prazar MD, Chapter President of NH Pediatric Society Rae Sonnenmeier, PhD, Clinical Assoc. Professor, Dept. of Communication Sciences and Disorders, Institute on Disability at the University of New Hampshire. Mark Rains PhD, Psychologist, Vienna Mt. Consulting, Maine Luanne Moody- Pediatric Psychiatric Nurse, North Shore Medical Center, Union Hospital, Lynn, MA Debra Nelson- Administrator. NH Head Start State Collaboration Office. NH DHHS/DCYF Claudia Ferber-Claudia Ferber, MS, Child and Family Programs Director, NAMI NH Jane Hybsch-Representative of NH DHHS Office of Medicaid Business and Policy Dr. Steven Chapman, MD- Director, Boyle Community Pediatrics Program, Associate Director of Child Health, Center for Primary Care and Population Health, Dartmouth Medical Center Watch Me Grow Steering Committee Liz Collins Title V Marie Mulroy – President NH Public Health Assc. Beth Achorn- Child and Family Therapist Riverbend Community Mental Health Debra Grobowski- Executive Director- Foundation of Seacoast Health Diana Weiner Child Psychiatrist Riverbend Community Mental Health A number of individuals wished to not be identified.

References Bruner, C.. A Framework for State Leadership and Action in Building the Components of an Early Childhood System Project LAUNCH webinar featuring Kay Johnson of Johnson Group Consulting. This is in reference to Medicaid funds: https://edc.adobeconnect.com/_a1002235226/p4gz3zrx3w4/?launcher=false&fcsContent=true&pbMode=normal Early Childhood Systems Working Group, National Governors Association, State Early Childhood Development System, (Washington, D.C.: National Governors Association, Early Childhood Systems Working Group, 2006), at: http://www.nga.org/Files/pdf/07EARLYCHILDFRAMEWORK.PDF Smarter Checklist by the National Center for Children in Poverty http://www.nccp.org/publications/pdf/download_136.pdf Opportunities in Public Policy to Support Infant and Early Childhood Mental Health: The Role of Psychologists and Policy Makers; Nelson, Florence: Zero to Three; Mann,Tammy:Frederick D. Patterson Research Institute; American Psychologist; February-March 2011, pages 129-137 Abelman, D.; Antal, P.; Oldham, E.; Printz, M.; Brallier, S.; Nelson, D.; Schreiber, E.; Brandt, K. Mental Health Services for New Hampshire’s Young Children and Their Families: Planning to Improve Access and Outcomes. Endowmentforhealth.com. 2009. Web. Feb. 2013. Retrieved from:  http://www.endowmentforhealth.org/resource-center/resource-center-detail.aspx?id=76 Graph of Insurance Status; NH State Health Facts.org New Hampshire Association for Infant Mental Health. (2009). From Peek-a-Boo to Parenthood: A Look at Early Childhood Mental Health in New Hampshire. Spark NH website Center on The Developing Child (2012). 5 Numbers to Remember About Early Childhood Development. Harvard University. Retrieved from http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/  Hart, B., & Risley, T. (1995). Meaningful differences in the everyday experiences of young American children. Baltimore, MD: Brookes.