CAPTA Summit
Penny Knapp MD
Medical Director, CA DMH
1/23/08
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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
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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)
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Attachment disrupted
Neglect or trauma early in life
Loss of safe context
Developmental risk
Risk of social-emotional disorders
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HEALTHY ATTACHMENT
DISTURBED ATTACHMENT
Reciprocal cuing, shared joy
Reduced reciprocal attachment
Child turns preferentially to
“mom”
Child does not seek comfort from
“mom” when distressed
“Mom” is able to comfort child
Child fails to respond to comfort
“Mom” helps child regulate
emotions
Child has poorly regulated
emotions, e.g. limited positive
affect, and/or excessive
irritability, sadness or fear
Child is free, in “mom’s”
presence to explore, learn
Child is preoccupied with making
or maintaining contact with
“mom.”
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Child is overwhelmed
and may:
• Dissociate
• Be hypervigilant
(+/or “hyperactive”
• Have disturbed
sleep, appetite,
concentration
DC 0-3 diagnostic
criteria
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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
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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)
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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
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The highest risk for
first episode of major
depression is during
childbearing years
Prevalence: 10-15%.
If left untreated, 3070% experience
depression for a year
or longer.
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Children of
depressed
mothers have
• Behavioral
problems,
• Emotional
problems,
• Problems with their
own relationships
later in life.
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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.
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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)
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Brief review of evidence
• Published evidence of efficacy of programs
Successful applications in California
• IPFMHI
• Best PCP (ABCD II)
• CIMH development teams for EBPs
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(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
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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 20022005
SECCS State Early Childhood Comprehensive
Systems
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1
Early Mental Health Initiative (EMHI) - At-risk
children K - 3. Run by DMH - legislative
appropriation
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CIMH Development teams to implement evidencebased practices
www.cimh.org
ABCD Screening Academy
All are successfully using standardized screening
tools
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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
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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
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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
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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
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Medicaid Program Strategy
Use of Screening tools
What screening approaches work?
What do you do after you screen?
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 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.)
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 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.
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o
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Identifying children for assessment
Identifying areas of need
Developing individualized interventions or
services
Evaluating progress
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o
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Fits constructs of interest
Psychometrics are acceptable
Fits children and families in program
Administration and scoring requirements fit
program staff and resources
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o
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Early childhood social and emotional
health
Factors that can adversely affect
emotional health
o Parental mental illness or substance abuse
o Domestic violence
o Unstable, unsafe or absent home
o Inadequate or absent supervision
o Inadequate or poor parenting skills
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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)
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Assessment
Referral
Provide parental support
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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.
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The person requesting the assessment wants the
answer to a question. e.g.:
1. Should the child be removed from his home?
2. Can the child attend regular school/preschool?
3. Why does the child have X behavior?
4. Can/should parent behavior change?
5. Does the child need medication?
The Assessment may answer the wrong question.
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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
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*For more information on: ABCD Initiative, go to :
http://www.nashp.org/_catdisp_page.cfm?LID=2A7898
8D-5310-11D6-BCF000A0CC558925
**ABCD II project, BEST-PCP, go to:
http://www.nashp.org/_docdisp_page.cfm?LID=C9C50
06C-F477-499B-902ACBDB9CC70B6B
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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
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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
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Executive summary at:
www.dmh.ca.gov/CFPP/infant_preschool.a
sp
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
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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.
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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
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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.
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Surprising:
• Very low numbers for (front-end) screening
and diagnostic services.
• Disparity in services to SED and Danger-toSelf populations
Of concern:
• Shelter/homeless pop’n low
• Immigrant pop’n low
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Five (of 9) priority populations are
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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
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