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Evaluation of Early Childhood Mental Health Systems of Care

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Evaluation of Early Childhood Mental Health Systems of Care Ilene R. Berson, Ph.D., NCSP and Maria J. Garcia-Casellas, MS, University of South Florida, Sarasota ... – PowerPoint PPT presentation

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Title: Evaluation of Early Childhood Mental Health Systems of Care


1
Evaluation of Early Childhood Mental Health
Systems of Care
  • Ilene R. Berson, Ph.D., NCSP and Maria J.
    Garcia-Casellas, MS, University of South Florida,
    Sarasota Partnership for Children's Mental
    Health
  • Joy S. Kaufman, Ph.D. and Amy Griffin, M.A. Yale
    University School of Medicine,
  • Building Blocks, Southeastern CT Mental Health
    System of Care
  • Cindy A. Crusto, Ph.D. and Meghan Finley, Ph.D,
    Yale University School of Medicine, Rhode Island
    Positive Educational Partnership

2
BRIEF WEBINAR ORIENTATION
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Setting the Context
8
Early Childhood System of Care Communities
  • Graduated Communities
  • Denver, CO
  • State of Vermont
  • 2005 Cohort
  • Allegheny County, PA
  • Los Angeles County, CA
  • Multnomah County, OR
  • State of Rhode Island
  • Sarasota, FL
  • Southeastern Connecticut

9
Early Childhood SOC Communities (contd)
  • 2008 Cohort
  • Burlington, NC
  • State of Delaware
  • Fort Worth, TX
  • State of Kentucky
  • 2009 Cohort
  • Alameda County, CA
  • Boston, MA
  • Guam

10
Evaluation of Early Childhood Mental Health
Systems of Care
  • Ilene R. Berson, Ph.D., NCSP and Maria J.
    Garcia-Casellas, MS, University of South Florida,
    Sarasota Partnership for Children's Mental
    Health
  • Joy S. Kaufman, Ph.D. and Amy Griffin, M.A. Yale
    University School of Medicine,
  • Building Blocks, Southeastern CT Mental Health
    System of Care
  • Cindy A. Crusto, Ph.D. and Meghan Finley, Ph.D,
    Yale University School of Medicine, Rhode Island
    Positive Educational Partnership

11
Acknowledgements
  • Building Blocks, Southeastern Mental Health
    System of Care
  • Kathleen Bradley, Ph.D., PI
  • Sue Radway, Ed.D., PD
  • Gigi Rhodes, LCSW, CS
  • Deirdre Cotter Garfield, MSW Families United
  • Miralys Camelo, Eval Assistant
  • Sarasota Partnership for Children's Mental Health
  • Chip Taylor, MPA, PI
  • Sarah Cloud, RN, MS, PD
  • Kristie Skoglund, Ed.D., LMHC, CD
  • Kelly Lewin, FSN
  • Rhode Island Positive Educational Partnership
  • Janet Anderson, Ed.D., PI
  • Anthony Antosh, Ed.D. Co-PI
  • Ginny Stack, MA, PD
  • Frank Pace, MSW, CD
  • Cathy Ciano, PSN RI
  • Jo-Ann Gargiulo, Eval Assistant

12
Early Childhood Systems of Care (EC-SOC)
  • EC-SOCs develop services and supports for
    children aged birth to eight years, and their
    families to
  • promote positive mental health
  • prevent mental health problems, and
  • provide mental health interventions
  • Although the rates of severe emotional
    disturbance in young children is nearly identical
    to that in older children (Egger, 2009), SOCs
    have almost exclusively served adolescents and
    school-aged children (Kaufmann Hepburn, 2007).
  • Although a growing number of EC-SOCs are being
    supported, little is known across communities
    regarding
  • demographic and background characteristics of
    these children
  • experiences that may have and continue to place
    them at risk for or protect them from psychiatric
    difficulties

13
Building EC Knowledge Base
  • In response to this gap in knowledge, the Phase V
    Early Childhood sites came together to
  • work with the national evaluation team to
    modify/add appropriate data elements for the
    early childhood population
  • select several common outcome measures so that
    more relevant longitudinal data could be gathered
    about young children
  • agree to share data so that it could be
    aggregated across sites

14
Purpose of Presentation
  • To present data pooled from three SAMHSA CMHS
    funded EC-SOC communities to
  • Better understand who are the young children aged
    birth to eight years and their families served.
  • Report on factors that may have increased
    childrens risk for social, emotional, and/or
    behavioral challenges or protected them from
    these difficulties.
  • Examine the mental health trajectories of young
    children served in these SOC communities.
  • Discuss work of the Diagnosis and Eligibility
    Workgroup including review of imminent risk.
  • Describe efforts to validate some DC 0-3R
    diagnoses.

15
Collaborating EC SOCs
  • Our three communities were funded in 2005 (Phase
    V)
  • Range in ages served (birth through 11 years)
  • Population of focus differs
  • Intervention of focus differs
  • Continuum of mental health services and supports
    are similar

16
New London Building Blocks
  • An initiative of the Southeastern Mental Health
    System of Care (SEMHSOC) in partnership with
    Families United, CT Department of Children and
    Families, Child and Family Services, United
    Community and Family Services, LEARN
  • Children under six years with serious social,
    emotional, and mental health challenges and their
    families
  • Serving all of New London County with a focus on
    underserved populations including military
    families, Hispanic/Latino families, teen parents,
    and homeless families
  • 300 children and their families to receive care
    coordination and a home-based intervention that
    focuses on the parent-child relationship and
    utilizes techniques of PBS

17
Rhode Island Positive Educational Partnership
(RIPEP)
  • Partnership among DCYF, RIDE, Sherlock Center,
    and early childhood systems
  • Integration of RI PBIS statewide initiative,
    RICASSP SOC and continuum of childrens
    behavioral health services, and early childhood
    systems
  • Children aged birth through11 years with serious
    social, emotional, and mental health challenges
    and their families
  • 80 schools/ECE sites will be involved
  • 700 children and families to be served

18
Sarasota Partnership for Childrens Mental Health
  • Comprised of representatives of the health
    department, mental health service agencies,
    school district, early learning and care
    community, and numerous other child serving
    organizations.
  • The population of focus includes children birth
    through age 8 and family members at risk of
    disrupted relationships due to
  • foster care placement or risk of placement,
  • prenatal exposure to alcohol and other
    substances,
  • risk of expulsion or exclusion from early
    learning environments, and/or
  • the presence of other environmental stressors
    (i.e., domestic violence, poverty, caregiver
    mental illness, homelessness).
  • The children have a DC03R or DSM-IV-TR
    diagnosis and prognosis that mental health
    challenges will last at least one year and
    require multi-agency interventions from at least
    two community service agencies.
  • Approximately 400 children and families expected
    to receive care coordination

19
Procedure
  • Descriptive Data (demographic and diagnostic)
    must be collected at intake and submitted for
  • All youth and families supported and served by
    the CMHS-funded system of care
  • Data sources
  • Administrative records
  • Caregivers
  • Evaluators (for specific questions)
  • Family Descriptive Information collected during
    Child and Family Outcome Study (every 6 months)
  • Intake data reported on here
  • Data source
  • Caregiver participating in Outcome study

20
Outcome Study Measures
21
  • Findings

22
System of Care Community
23
Demographics (n728)
24
Demographics, cont.
25
Custody Status
N370
26
Referral Source
(n708)
27
Presenting Problems
(n427)
28
Presenting Problems Reported for Young Children
(n465)
29
Educational Information
30
Health History
31
Family Characteristics
32
Child and Family Risk Factors
33
Services Received Prior to Enrollment
34
  • Preliminary Results from Longitudinal Outcome
    Study

35
Procedure
  • Supplemental measures to the SAMHSA required
    Longitudinal Child and Family Outcome Study
  • Baseline, 6months, 12 months
  • Caregiver report
  • Interviews conducted by trained interviewers
  • Interviews conducted in caregivers preferred or
    primary language
  • Interviews conducted in familys home or another
    location

36
Outcome Study Measures
37
Risk Factors and CBC Analysis
  • Predictors (Risk factors)
  • number of different types of trauma events
  • maternal depressive symptoms
  • parenting stress (total scale)
  • Controlled for childs age and childs gender
  • Outcome CBC total problems score at baseline,
    6-, and 12-months

38
Risk Factors and CBC Results
  • CBC Total Problem Scores decreased over time
  • At baseline
  • number of different types of trauma events
    experienced was significantly related to higher
    CBC scores
  • lower levels of maternal depression were
    significantly related to higher CBC scores
  • higher parenting stress was significantly related
    to higher CBC scores
  • Parenting stress was significantly related to
    trajectory of CBC scores over time
  • children whose parents had higher parenting
    stress at baseline improved more quickly than
    children whose parents reported less stress at
    baseline

39
Protective Factors and CBC Analysis
  • Predictors (Protective factors)
  • DECA Initiative, self-control, attachment
  • Controlled for childs age and childs gender
  • Outcome CBC total problems score at baseline,
    6-, and 12-months

40
Protective Factors and CBC Results
  • At baseline
  • higher self control was significantly related to
    lower CBC scores
  • older children were significantly more likely to
    have higher CBC scores
  • Only age was significantly related to trajectory
    of CBC scores over time
  • older children started out higher on CBC at
    baseline but exhibited fewer problems at 6 months

41
Discussion
  • With regard to risk factors, parenting stress was
    significantly related to trajectory of CBC scores
    over time
  • potential benefits to early intervention
  • clinical vs. statistical significance
  • In the examination of protective factors, only
    age was significantly related to trajectory of
    CBC scores over time
  • older children started out higher at baseline but
    exhibited fewer problems at 6 months

42
Translating Research into Practice Imminent Risk
and a Public Health Approach to Early Childhood
43
A Public Health Approach to Early Childhood
  • Promotion of positive mental health through
    comprehensive service delivery
  • Prevention of conditions commonly associated with
    emotional disorders, including exposure to
    trauma, to preserve young childrens mental
    health.
  • Earliest possible identification and intervention
    in mental health problems, to restore positive
    functioning and well being.
  • The approach focuses on both strengthening
    services and supports for children with serious
    emotional disorders and their families, and on
    prevention and early intervention strategies for
    all children.
  • To achieve this public health approach,
    cross-system partnerships are needed within
    communities to implement and sustain such
    services.

44
Public Health Implications
  • Enhance Early Childhood System of Care
    Eligibility
  • Imminent risk
  • Resilience-informed approach
  • Focus promote resilience
  • Goal reduce negative outcomes
  • Future directions
  • Explore additional risk factors
  • Identify/design screening tools

45
Early Childhood Community of Practice Diagnosis
and Eligibility Workgroup
  • Convened at Early Childhood Pre-Conference
    meeting in New Orleans, July 2007
  • Draft Concept Paper presented to the Early
    Childhood Community of Practice participants at
    the Training Institutes in July, 2008 in
    Nashville

46
Imminent Risk
  • Cumulative risk screening that may help focus
    preventive intervention where it will be most
    efficient and effective (e.g. based on number of
    risk factors experienced, occurring after risk
    exposure and before development of problems, in
    the context of service resources, etc.).
  • Appropriate screening tools can be used to
    identify children and get them into the services
    they need to prevent young children from
    developing more severe and persistent disorders.

47
Resilience-Informed Approach
  • Combination of high risk-status and inadequate
    protective factors compound to intensify the
    detrimental effect on a childs functioning and
    emotional well being. The results of our research
    highlight the relevance of risk and resilience to
    early childhood mental health.
  • Since children are impacted greatly by adult risk
    behaviors (i.e., mental illness, drug abuse,
    criminal activity), a complementary focus on
    strengthening protective factors and promoting
    resilience within the family may help reduce the
    negative outcomes of current and future risk
    exposure.

48
Summary and Next Steps
  • Study results support using trauma exposure and
    protective factors to identify children at
    imminent risk for emotional and behavioral
    problems.
  • Early intervention efforts should focus on
    strengthening protective factors and promoting
    resilience, which may reduce the negative
    outcomes of current and future risk exposure.
  • Future directions should include the development
    and application of screening tools to identify
    risk and resilience for early childhood mental
    health.
  • Ongoing research should investigate additional
    risk factors (e.g., prenatal tobacco, alcohol,
    and/or drug use, caregiver strain, poverty) that
    may place children at imminent risk for emotional
    and behavioral problems.

49
  • Validation of the DC 0-3R

50
Developing Diagnostic Classification Systems for
Young Children
  • Research data in preschool psychopathology are
    so scant that the extrapolation of most diagnoses
    to preschool age is unsupported by any convincing
    research data. (Postert et al., 2009)
  • Challenges
  • Preschool children are limited in their ability
    to self-report due to cognitive immaturity and
    limited verbalizing skills
  • Compared to other age groups, preschool children
    represent the group most variable in
    developmental changes in important domains like
    emotional regulation, interpersonal interactions,
    play, control of physical functions, motor skills
    and language.
  • Thresholds for the frequency of symptomatic
    behavior in older children are not transferable
    to preschoolers if these behaviors are
    developmentally normal in young children.
  • In early child mental health development
    biological and environmental factors closely
    interact requiring a dynamic model of mental
    health development. However, the difficulty of
    developing reliable measurements of relationship
    factors remains a serious empirical challenge.

51
Challenges of Diagnostic Classification Systems
  • DSM IV
  • Offers only a small number of child psychiatric
    disorder categories for young children and lack
    developmentally sensitive adaptations
  • Lacks integrated emphasis on contextual factors
    influencing developmental psychopathology in
    young children, i.e., child-parent attachment,
    parental sensitivity and interactive behavioral
    patterns
  • Research Diagnostic CriteriaPreschool Age
    (RDC-PA)
  • 2001 to 2002 task force from the American Academy
    of Child and Adolescent Psychiatry (AACAP)
  • Aim devise complementary and developmentally
    sensitive modification to the appropriate
    categories of DSM-IV-TR based on empirical data
  • 17 diagnostic categories of the DSM-IV
    classification system were deemed relevant to
    children ages 0-5 years
  • Agoraphobia without history of panic disorder,
    social phobia, obsessive compulsive disorder and
    generalized anxiety disorder have insufficient
    evidence-based data to warrant a revision but
    their clinical relevance to young children
    required their provisional inclusion into RDC-PA
    without proposal for modification.

52
Purpose of the Diagnostic Classification 0-3R
(DC0-3R)
  • To focus on the first 3-4 years
  • To provide a developmentally sensitive diagnostic
    tool for young children that frames diagnosis as
    an ongoing process and leads to the development
    of a comprehensive prevention and/or treatment
    plan
  • To consider the impact of relationships and
    obtain a complete understanding of a young child,
    in the context of his/her family
  • To consider problems/behaviors not captured by
    other classification systems
  • To complement other systems (e.g., DSM, ICD)

53
DSMIV Axis I II DiagnosesChildren 4-8 Years
of Age
Because children/youth may have more than one
diagnosis, percentages for diagnoses may sum to
more than 100. a Substance Use Disorders
include caffeine intoxication. b V Code refers
to Relational Problems, Problems Related to Abuse
or Neglect, and additional conditions. Percentage
excludes V71.09 (No Axis I or II diagnosis).
54
DC0-3R Axis I DiagnosesChildren 0-3 Years of Age
Because children/youth may have more than one
diagnosis, percentages for diagnoses may sum to
more than 100.
55
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58
Average Scores of Child Behavioral and Emotional
Problems for Children Ages 1½ to 5 at Intake
For the syndrome scales, T scores less than 67
are considered in the normal range, T scores
ranging from 67-70 are considered to be
borderline clinical, and T scores above 70 are in
the clinical range.
59
Looking Toward the Future
60
  • Next Steps
  • Our sites will continue to collect this data.
  • Plan to submit a R01 this June to create a data
    repository so that we can pool the data across
    sites to allow for a more comprehensive
    understanding of the characteristics of children
    served and the impact of EC SOCs for young
    children and their families overtime.
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