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Infant and Early Childhood Mental Health (IECMH): What the Science Tells Us and How New York City and State
Initiatives are Aligning to Advance IECMH
Evelyn J. Blanck, LCSW, Associate Executive Director, New York Center for Child DevelopmentShirley Berger, DrPH, Bureau of Children, Youth, and Families, NYC Dept of Health and Mental Hygiene
Jacqueline Martello, MA, Division of Integrated Community Services for Children and Families, NYS Office of Mental Health
Overview
• Infant and early childhood mental health: What the science tells us
• DC:0-5 diagnostic system for children birth to 5: NYS initiative to train
professionals
• NYC Early Childhood Mental Health Network: Pairing clinical services
and capacity building
• New Medicaid CFTSS services: Opportunities for young children and
their families
Infant and early childhood mental health: What the science tells us
What is Infant and Early Childhood Mental Health?
The capacity of the child from birth to age five to:
• Experience, regulate, and express the full range of positive and
negative emotions
• Form close and secure interpersonal relationships
• Explore the environment and learn
All within the context of family, community and culture.
(Zero to Three, 2004)
Prevalence of Mental Health Disorders
• Between 9.5 and 14 percent of US children ages birth to 5 experience social-emotional problems that negatively affect their functioning, development, and school readiness (Brauner & Stephens, 2006)
• 1 in 6 U.S. children aged 2–8 years (17.4%) has a diagnosed mental, behavioral, or developmental disorder (Cree RA, Bitsko RH, Robinson LR, et al., 2016)
Return on Investment
• James Heckman, Nobel prize winning economist has analyzed the return on governmental and other social investment in human capital at various stages in individuals’ lives
• Interventions early in the life cycle of disadvantaged children have much higher economic returns than later interventions. The highest returns are in prenatal period to three years
• Early interventions reduce crime, promote high school graduation and college attendance, reduce grade repetition and special education costs, and help prevent teenage births (James J. Heckman and Dimitriy V. Masterov, 2007)
Brain Research
• Neuroscientists have discovered that the quality of early childhood relationships affect brain architecture.
• Brain scans of very young children with strong nurturing primary relationships were very different from the brain scans of children with disorganized attachments to primary caregivers or of children with trauma or toxic stress.
• The greatest source of danger and unpredictability for an infant or young child is the absence of a caregiver who reliably and responsively protects and nurtures the child (Cicchetti and Lynch, 1995).
Development in One Domain Affects Development in Others
• Children from birth to age 5 rapidly develop foundational capabilities in areas
such as cognition, social, emotional, communication, and regulation all of
which are intertwined and upon which later subsequent development builds
(Shonkoff and Phillips, 2000).
• Particularly for young children, we can no longer think of mental health and
development as separate but rather intertwined.
• The co-morbidity between mental health and child development is well
established.
• Social-emotional development sets the foundation for healthy development.
If social-emotional development isn’t strong, other development will slide.
Relationships are Key
• Infants and young children develop in the context of relationships; in order to treat young children, need to be relationship focused
“We know that what happens in the early years either sets the stage for sturdy or fragile existence. Children’s development depends on the quality and reliability of their relationships”
(Shonkoff, Harvard Center on the Developing Child)
• The quality and consistency of early relationships impact young children’s:
• learning• sensory processing • ability to regulate themselves and form relationships
Relationship Based Treatment
• “There is no such thing as a baby, only a baby and someone” (Winnicott, 1971)
• Treatment for young children must aim to strengthen key adult-child relationships, ensure the well-being of parents and other caregivers and strengthen their ability to provide critical supports for young children’s social-emotional well-being and growth.
The Importance of Attachment
• Children come into this world wired for relationships and to be active partners in their own survival (Bowlby, 1969)
• A key element in the parent-child relationship is the quality of attachment. The capacity of the caregiver to be sensitive to the child’s cues and respond empathically to emotional signals provides the foundation for the child’s secure and healthy development. (Ainsworth, 1969)
Assessment of the Parent-Child Relationship
• In assessing the parent child dyad, need to recognize that stresses can stem from characteristics of the child, characteristics of the parent or the interaction between both
• Child can exhibit different temperaments and development (a parent may experience a child as difficult to soothe, different sensory profiles, developmental challenges or delays)
• A parent may be depressed or have their own history of inadequate or abusive parenting or their own history of trauma which interferes with their ability to respond to their child’s need
Assessment of the Parent-Child Relationship Maternal Mental Health
• The caregiver’s ability to be responsive to the needs and cues of the child may be impacted by maternal depression, mental illness, substance abuse or cognitive delays.
• For example, some ways maternal depression can influence parenting practices
• Compromise mother’s judgment on supervising health and safety issues
• Less likely to be affectionate or talk, play or interact with their children which impacts the development of a positive mother-infant attachment
• 10 to 20% of mothers experience postpartum depression. Depression is treatable.
Ghosts in the Nursery
• Fraiberg and her colleagues (1975) introduced the metaphor "ghosts in the nursery" to describe the ways in which parents, by reenacting with their small children scenes from the parents’ own unremembered early relational experiences of helplessness and fear, transmit child maltreatment from one generation to the next (Fraiberg, Adelson and Shapiro, 1975).
• Parents unconsciously repeat their own early relationships that may affect their current caregiving patterns. Trauma can be transmitted from generation to generation.
Parent-Child Goodness of Fit
• Consideration should be given to the match/mismatch between a child’s individual characteristics such as temperament and developmental functioning and the characteristics of the caregiving environment.
• Problem behaviors may reflect a mismatch between the child and caregiving environment, developmentally inappropriate caregiver expectations or limitations of the caregiver to meet the child’s needs (Seifer, 2000)
Effective Treatment Strategies
• Support dyadic treatment with evidence-based or research-informed models
• Support evidence-based parenting programs that promote parenting skills needed to strengthen the parent-child relationship and the child’s social-emotional functioning
• Address the mental health needs of the caregivers
DC:0-5 diagnostic system for children birth to 5: NYS initiative to train professionals
What is the Diagnosis and Classification System of Infancy and Early Childhood Mental Health:DC:0-5
DC:0-5 is a multi-axial system that considers a child’s clinical disorder only after issues such as the child’s health, development, psychosocial stressors, and culture as well as the nature of the child’s relationship with important caregivers have been assessed.
Axis I: Clinical DisordersAxis II: Relational ContextAxis III: Physical Health
Conditions and ConsiderationsAxis IV: Psychosocial StressorsAxis V: Developmental
Competence
New York State
• NYS Office of Mental Health (OMH) has been actively collaborating with the NYS Department of Health (DOH) toward making DC:0-5 the recommended diagnostic tool for children birth to 5
• Discussion about this has been focus of NYS Infancy Leadership Team
• Developing a crosswalk to ensure that all diagnoses are billable
• This is consistent with the growing movement across the country where many states are recommending or allowing the use of this diagnostic tool for children birth to age 5
DC:0-5 trainings are being offered under the Preschool Development Grant Birth through Five Initiative (NYS B5), the New York Center for Child Development (NYCCD) and the New York State Office of Mental Health (OMH) in collaboration with CTAC are offering statewide training
https://www.ccf.ny.gov/council-initiatives/nysb5/nysb5-activities/
Who we areNew York Center for Child Development (NYCCD)
• A major provider of early childhood mental health services in New York
• Long history of providing system-level expertise to inform policy and support the field of Early Childhood Mental Health through training and direct practice
McSilver Institute on Poverty Policy and Research
• Community and Managed Care Technical Assistance Centers (CTAC/MCTAC) provide training, consultation and technical assistance to all behavioral health agencies in NYS.
The DC:0-5 training builds upon a strong partnership as the ECMH Training and Technical Assistance Center (TTAC)
Why DC:0-5 Was Developed
• DC:0-5 was developed since existing classification systems such as DSM-5 did not adequately reflect the unique developmental and relational experiences of infants and young children
• Existing diagnostic systems did not capture mental health disorders that are typically first diagnosed in infancy and early childhood such as regulatory disorders and care-giver- child relationship disturbances
• Cross-walked with other diagnostic tools including DSM-5 and ICD-10
Incorporates Developmental and Relationship Issues
• We know that the domains of development in young children are intertwined and that social-emotional health sets the foundation.
• DC:0-5 incorporates developmental issues that may affect symptom presentation in young children
• Assesses relationships, the caregiving environment and the adaptive quality in relationships
Why Diagnose in Infancy and Early Childhood?
• Provides common language to allow professionals across disciplines to communicate accurately about children’s disorders
• Helps health professionals to ask better questions instead of using diagnostic tools that focus on symptoms or conditions of older children or adults, and leads to more accurate diagnoses
• When needed, can help guide the most appropriate treatment interventions at a time of maximum impact
• Provides a helpful guide to clinical formulation
• Supports reimbursement and treatment authorizations
The Balancing Act
Copyright © 2016 ZERO TO THREE. All rights reserved
Identify children with clinically impairing disorder
to increase chance of access to evidence-based
treatments
Avoid pathologizing children demonstrating
normal variations of typical development
Safeguards Against Over-Diagnosing
• DC:0-5 is a multi-axial system that considers the child’s clinical disorder
only after all contextual issues (e.g. health and development, psychosocial
stressors, culture), and the nature of the child’s relationship with
important caregivers, have been assessed and integrated.
• All disorders have a clear algorithm
• Takes into consideration what is typical versus atypical development
• Considers duration of the symptoms
• Takes into account developmentally normal behaviors
Impairment for Every Disorder
• In order to diagnose, all disorders need to meet a criteria of impairment.
• Symptoms of the disorder significantly impact the young infant’s/young child’s and/or family’s functioning in one or more of the following ways:
1. Cause distress to the infant/young child
2. Interfere with the infant’s/young child’s relationships
3. Limit the infant’s/young child’s participation in developmentally expected activities or routines
4. Limit the family’s participation in everyday activities or routines
5. Limit the infant’s/young child’s ability to learn and develop new skills, or interfere with developmental progress
6. Symptoms are persistent and are seen in multiple settingsCopyright © 2016 ZERO TO THREE. All rights reserved
Webinar on DC:0-5
• Kick-off Presentation viewed by 188 participants and the rebroadcast by 166 totaling 354 viewers
• Donna Bradbury, Associate Commissioner NYS Office of Mental Health discussed NYS’s efforts to make DC:0-5 the recommended Diagnostic tool for children birth to age 5
• Presented by: Kathleen Mulrooney, MA, LPC, IMH-E® IV ZERO TO THREE
New York State Trainings - DC:0-5
Location DateAlbany Nov 6 & 7
Albany Dec 5 & 6
Buffalo July 11 & 12
Buffalo Nov 18 & 19
Ithaca Sept 26 & 27
Long Island July 25 & 26
Long Island Dec 12 & 13
NYC Sept 12 & 13
NYC Oct 24 & 25
NYC Nov 14 & 15
NYC Nov 21 & 22
NYC Dec 5 & 6
Plattsburgh Oct 17 & 18
Poughkeepsie Oct 7 & 8
Rochester Sept 30 & Oct 1
Rochester Dec 9 & 10
Syracuse Oct 2 & 3
Syracuse Oct 10 & 11
Westchester Sept 26 & 27
Westchester Nov 4 & 5
Westchester Dec 9 & 10
Training Structure
• Have provided 16 trainings with 623 participants to date
• All trainings are conducted by licensed psychologists or psychiatrist
• Trainings are one and half days
• CEU credits are offered
• Each participant receives a copy of the DC:0-5 manual
• Participants are offered up to three learning collaborative calls following each training
• Participants include social workers, psychologists, early interventionists, teacher and special education professionals, pediatricians and others
NYC Early Childhood Mental Health Network: Pairing clinical services and capacity building
NYC ECMH Network
• Build the capacity of professionals from a range of disciplines to support the social-emotional development of young children and strengthen their resilience
• Increase access to high-quality evidence-based mental health services and supports for children birth to five and their families
• Launched Fall 2016
ThriveNYC – “ACT EARLY”
Network of Service Providers and Training Center
Specialized Article 31 ClinicsMental Health
Treatment
Family Peer Support
Mental Health Consultation
Licensed mental health clinics offer 3 services:
• Mental Health Treatment• To children birth to five, their siblings, and
parents/caregivers (dyadic or family-based, trauma informed models)
• Mental Health Consultation• Capacity building support to teachers, staff
and caregivers at early care and education sites
• Family Peer Support• Peers integrated into team to support parents and
caregivers navigating child-serving systems
Mental Health Treatment
• 2,500 families with children birth to five have received specialized mental health treatment services through Network clinics (since Fall 2016)
• On FACS survey, parents/caregivers whose children were receiving treatment, agreed with the following*
• staff treated them with respect (96%)
• they were included as partners in planning their children’s services (91%)
• the services their child/family were receiving were helpful to them (85%)
Locations of Network clinics and satellites
*Family Assessment of Care Surveys(FACS) completed during the months of October 2018 and May 2019; n=405.
Consultation in Early Care Sites
39
• Framework: Georgetown University (Center of Excellence)
• A multi-level, preventive intervention that partnersmental health professionals with early childhood providers and with parents/ caregivers to build their capacity to support children’s social and emotional health and development
• Consultants: Master’s level mental health professionals with early childhood expertise, based in Article 31 clinics
• Site: Center-based early care
• Dosage: 1 day per week for the duration of the year
• Caseload: 5 sites, 3 classrooms per site
Levels of Mental Health Consultation
Site/Programmatic
Classroom
Child/Family
Connect family to mental health care
Reach and Impact of Consultation Program (Sept 2017-June 2019)
Reach
127 early care sites
2,430 early care staff, including teachers,
received consultation
Types of consultation
% time spent:
71% classroom level
15% child/family
14% programmatic
Teacher feedback on new skills
95% of teachers reported changing
much or some aspects of their practice in
managing children’s challenging behaviors and 92% in preventingchallenging behaviors
(n=199 who completed latest teacher impact survey June 2019)
Connection to clinical care
Among families referred to Network clinics: 79% referred
from early care attended appointment
vs. 63% referred from other sources
attended appointment
• Almost 3,000 parents/caregivers have received FPSS (since launch in Fall 2016)
• Services have primarily taken place in clinics and at early care sites
• The top two services:
o Engagement and bridging
o Providing emotional support
61% 30%Early Care Sites
7%Community/OtherClinic Home
2%
Family Peer Support Services (FPSS)
NYC ECMH Training and TA Center (TTAC)
• NYCCD, in partnership with the McSilver Institute of Poverty Policy and Research, was selected as the NYC Early Childhood Mental Health Training and Technical Assistance Center (TTAC)
• TTAC combines NYCCD’s early childhood mental health clinical and training expertise with the strong training, consultation, and technical assistance of McSilver
TTAC Approach
TTAC is tasked with building capacity and competencies of mental health professionals and early childhood professionals in family serving systems to identify and address the social-emotional needs of young children and their
families across NYC
Tiered model of training with
varying intensities; linked to network
of service providers
Flexible and responsive to
needs of practitioners and
community mental health needs
Multi-year process of trainings, and alignment with
NYS-AIMH competencies for
endorsement
Community of practice approach
guided by best practices;
emphasizes business
sustainability
TTAC’s Tiered Approach
Tier 2:
Clinical staff and
supervisors in other mental health clinics
serving children
Tier 1:
All ECTC staff: supervisors,
clinicians, consultants, and family
peer advocates
Tier 3: Early Childhood Allied Professionalsin other child-serving systems
Number Trained:Tier 3: 1331 Tier 2: 865 Tier 1: 261 EI eLearning: 739Total: 3,196
Total number of individuals who attended at least one training offered since the Network launched (2016-October 2019)
Clinical
. .
Trauma & self-care
workshopsDC 0-5
ECMH Consultation
Georgetown Model
Foundational Topics
Assessment, Play, Sensory Integration,
Child Development
Business Sustainability
Billing Workshops
Reflective Supervision
Interpersonal
Psychotherapy
IPT
Evidence-Based Practices and trainings
Webinar Series
Find Archived Webinars on our Website
Visit http://www.ttacny.org/ Click on “Past Events”
• Psychiatric Medications in Young Children
• Clinical Work with Young Children in Foster Care
• Sensory Integration and Self-Regulation: Sensory Contributions to Young Children’s Social-Emotional Development
• Supporting Play: Development, Meaning, and Growth
• What Can Early Childhood Mental Health Practitioners Do About Maternal Depression?
• Understanding Effective Infant and Early Childhood Mental Health Consultation (IECMHC)
Foundations of Social-Emotional Development in Infants and Toddlers
• http://socialemotionaldevelopment-zps.talentlms.com/index
New Medicaid CFTSS services: Opportunities for young children and their families
Children and Family Treatment
and Support Services (CFTSS)
Children and Family Treatment
and Support Services (CFTSS)
What are CFTSS?
• Mental health and/or substance abuse services in NYS Medicaid
• For children ages birth to 21
• Available to eligible children/youth enrolled in Medicaid
• Services can be provided at home, in the community, or wherever children/youth and their families feel comfortable
Children & Family Treatment and Support Services (CFTSS) Service Types
• Other Licensed Practitioner (OLP) –individual, group, or family therapy at home or in the community for a children/youth who have mental health or substance use needs.
• Community Psychiatric Supports and Treatment (CPST) – support at home and in the community to help improve relationships with family, friends and others
• Psychosocial Rehabilitation (PSR) – help with relearning skills to help support the child/youth in their home, school and community. Children and youth must have a mental health or substance use diagnosis to receive this service.
• Family Peer Support Services (FPSS) (CFTSS Beginning July 1, 2019) - supports families and caregivers to help address the mental health or substance use needs of their child. Provided by an individual with their own lived experience
CFTSS Timeline
Available as of January 1, 2019
Expanding on July 1, 2019
Expanding on January 1, 2020
• Other Licensed Practitioner
• Community Psychiatric Supports and Treatment
• Psychosocial Rehabilitation
• Family Peer Support Services
• Youth Peer Support and Training
• Crisis Intervention
An Integrated Service Approach
• CFTSS offers the ability to combine clinical and rehabilitative, supportive services to practice and reinforce therapeutic interventions in the child’s natural environment
• CFTSS are designed to compliment other child-serving systems/programs to best meet the needs of children and families
Enhanced Continuum of Care
• CFTSS can be provided to children who may not be appropriate for clinic services, due to age of the child, early demonstration of symptoms, inability to engage in office-based interventions, etc.
• CFTSS is intended to be provided in the child’s natural environment, across various settings to best meet the needs of the child and family including, child care settings, Pre-K programs, community
Additional Resources
FOR GUIDANCE DOCUMENTS AND PROVIDER RESOURCES:
• Children and Family Treatment and Support Services Provider Manual for EPSDT Services (includes Medical Necessity Criteria)https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/updated_spa_manual.pdf
• Child/Youth and Family CFTSS Education and Outreach Materialshttps://www.omh.ny.gov/omhweb/bho/childrensmc.html
• Find an OMH CFTSS Designated Providerhttps://my.omh.ny.gov/bi/pd/saw.dll?PortalPages&PortalPath=/shared/Mental%20Health%20Program%20Directory/_portal/Mental%20Health%20Program%20Directory&page=Advanced%20Search&Action=Navigate
Parting Thought
Thank you!
Questions and Discussion