Over the past several years, Massachusetts has expanded its efforts to improve the emotional well-being of our youngest children. Massachusetts is way ahead of other states in developmental screenings for young low-income children, according to a newly-released report from the Annie E. Casey Foundation. Developmental screenings, which can identify at even a very young age whether a child is at risk for developmental delay or may be exhibiting early signs of mental health needs, are an essential first step in ensuring the emotional well-being of the youngest members of our Commonwealth. There is ample evidence that sound mental health begins in even the earliest childhood and can shape a child's life well into the future. Moreover, with innovations in expanding the assessment of postpartum depression, Massachusetts is also recognizing the impact of a mother's emotional well-being on the health of children.
Recent data show that new efforts in Massachusetts have had a meaningful impact. Analysis of data from the National Survey of Children's Health shows that more than two-thirds of low-income children under age six in Massachusetts received a developmental screening, compared to less than one-third of children nationwide. Massachusetts is so far ahead of other states in providing screening that the next closest stateNorth Carolinaisn't even close. Just over half of low-income children under age six in North Carolina were screened.
Why is Massachusetts so far ahead?
Massachusetts has made a significant commitment to screening children, particularly low-income children who receive publicly-subsidized health insurance. The Massachusetts Medicaid programMassHealthnow requires that all children receive a behavioral health screening at pediatric well-child visits. As of August 2013, there were more than 550,000 children covered by MassHealth, or almost two out of every five children in the Commonwealth. This requirement has had a dramatic impact on the rate of pediatric mental health screenings.
The expansion of pediatric screening did not come easily. In January 2006, the U.S. District Court ruled that the Commonwealth was in violation of the federal Medicaid act because the state was failing to provide home-based mental health services to children with what was called "serious emotional disturbance." This decision was in response to a class action lawsuit referred to as Rosie D. v. Romney. The courts found that a failure in the mental health system for children in Massachusetts was forcing thousands of children with "serious emotional disturbance . . . to endure unnecessary confinement in residential facilities or to remain in costly institutions far longer than their medical conditions require."
The courts mandated a remedy that profoundly altered the mental health system for low-income children' in Massachusetts. The state created the Children's Behavioral Health Initiative (CBHI), which among other things requires that primary care providers offer standardized behavioral health screenings at well child visits, and then creates a new system of mental health services and supports for children found to have significant mental health concerns.
Screening is not enough
Although screening for emotional or behavioral concerns is important, it is only a first step in a child's emotional health. It is crucial that periodic and standardized evidenced-based assessment be followed by accessible and effective treatment with a well-trained group of providers with expertise in children's mental health.
If upon screening a child seems to be in need of services, the Children's Behavioral Health Initiative also includes MassHealth coverage for a variety of treatments: outpatient therapy, in-home therapy, around-the-clock immediate crisis intervention, and support for the coordination of care for children with intensive needs. In some instances, CBHI will also cover in-home behavioral services, therapeutic "mentors" to provide guidance and modeling of appropriate behavior in the community, and supports for family members.
What has been particularly significant with the roll-out of CBHI has been the creation of a state-wide network of community mental health programs to provide services to children with significant behavioral health needs and their families. Moreover, mental health providers are expected to respond rapidly to referrals (within 24 hours by phone and offering an appointment within three days of that initial phone contact.)
Even with the expansion of screening and the recognition of the need for an extended community-based network of mental health treatments and supports, a recent report from the Children's Mental Health Campaign noted limited access to services across the Commonwealth, with significant variation in service access across different geographic regions. The report also notes that limitations in available data make it impossible to monitor treatment outcomes.
Support for pediatricians
The Massachusetts Department of Mental Health funds a program known as the Massachusetts Child Psychiatry Access Project (MCPAP). This program supports and provides education to any primary care clinician who has a question about how to handle a mental health concern. Primary care clinicians simply enroll in the program, and then have telephone consultation access to licensed child and adolescent psychiatrists, psychotherapists, and care coordinators who are available to consult on issues such as mental health diagnosis and treatment, psychiatric medication management, referral to community mental health resources or parental guidance.
With the implementation of CBHI and the offering of a mental health screening for all children on MassHealth, more and more pediatricians are likely confronting mental health concerns unfamiliar to them and have questions about follow-up or possible treatments. The consultation role provided by MCPAP therefore becomes central to the provision of mental health services for children. In fact, data from the MCPAP program shows that in the years since the implementation of CBHI, the utilization of the MCPAP program has more than doubled, with close to 21,000 documented "encounters" in FY 2012. In FY 2014, the state budget included additional funding designated for the program, which allowed for the full expansion of the program to include consultation coverage five days a week (rather than four.)
Recognizing the importance of mothers for the well-being of children
As MCPAP provides consultative support to pediatricians on children's mental health screening, diagnosis and treatment, the program has stepped in to take a major role in recognizing the importance of assessing the emotional well-being of the mothers, particularly the mothers of newborns. As the program notes, pediatricians are critical in identifying parents' mental health concerns, including postpartum depression.
Massachusetts has been making significant strides in advancing the recognition of postpartum depression and expanding treatment of it as an identifiable mental disorder. In FY 2011, the Massachusetts Legislature created a special commission on postpartum depression, charged with determining the best ways to prevent, detect and then treat postpartum depression.
According to the Annie E. Casey study recently released, recent data show that in Massachusetts, there are close to 27,000 young children in households whose mother reported having poor or fair mental or emotional health. Since poor maternal mental health puts children at risk, these data suggest that close to one out of every 25 young children is at risk, simply due to their mother's emotional well-being.
Through the efforts of the Postpartum Depression Commission, the MCPAP program will be adding postpartum depression to the areas in which it provides consultation, advocacy and support. A working group at the Mass. Department of Public Health has created and distributed standards for postpartum depression and screening. Significantly, these standards have been distributed to pediatric providers.
There have been two important developments in the expansion of screening and treatment for postpartum depression. In FY 2014, the state budget included funding for a pilot program in four communities to support a part-time community health worker to assist physicians working with women who receive a positive screen for postpartum depression. The MCPAP program will also be expanding its services to provide telephone consultation for postpartum depression.
Making the connections
The increase in behavioral screening of low-income children in Massachusetts is a significant accomplishment, thanks in part to the implementation of the Children's Behavioral Health Initiative resulting from the Rosie D. lawsuit. The requirement to offer screening has also been accompanied by a systematic expansion of community-based mental health services and family supports, as well as intensive services for children with serious emotional disorders.
At the same time, there has been an expansion of the availability of psychiatric consultation services for primary care clinicians who may not have specific expertise in mental health diagnosis, medication management and treatment, and the Massachusetts Child Psychiatry Access Project has been expanded to address that need.
Similarly, pediatricians are being better educated about the role of maternal and paternal emotional well-being in the healthy development of children, and are being educated in screening for postpartum depression. Unfortunately, although the MassHealth program through CBHI reimburses pediatricians for screening all low-income children for mental health concerns, MassHealth does not reimburse providers for screening parents for postpartum depression, even though this population of low-income mothers and fathers is particularly at risk.
Even so, the screening for mental health disorders is not enough to improve child well-being, and there is not yet a wide enough network of trained mental health providers available to meet the needs of children and families. In order to turn our relative success in behavioral health screenings into improved child mental health, it would be important for screenings to be followed up with mental health services when needs are identified. For services to be effective, trained providers across all geographic regions of the state would work with community- and family-center supports that are culturally appropriate for all of the young residents of Massachusetts and their parents. Without this integrated system of mental health care, the youngest and most vulnerable members of the Commonwealth will not be able to reach their best potential in the years to come.