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Characteristics of Children Presenting to Early Childhood Mental

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Characteristics of Children Presenting to Early Childhood Mental Powered By Docstoc
					    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
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Setting the Context
       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*
       Early Childhood
   SOC Communities (cont’d)
• 2008 Cohort
  – Burlington, NC
  – State of Delaware
  – Fort Worth, TX
  – State of Kentucky
• 2009 Cohort
  – Alameda County, CA
  – Boston, MA
  – Guam
    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
             Acknowledgements
Building Blocks, Southeastern     Rhode Island Positive Educational
Mental Health System of Care      Partnership
• Kathleen Bradley, Ph.D., PI     • Janet Anderson, Ed.D., PI
• Sue Radway, Ed.D., PD           • Anthony Antosh, Ed.D. Co-PI
• Gigi Rhodes, LCSW, CS           • Ginny Stack, MA, PD
• Deirdre Cotter Garfield, MSW    • Frank Pace, MSW, CD
  Families United                 • Cathy Ciano, PSN RI
•Miralys Camelo, Eval Assistant   •Jo-Ann Gargiulo, 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
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
   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
      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 children’s
    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.
       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
     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
      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 children’s 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
    Sarasota Partnership for Children’s 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
        a) foster care placement or risk of placement,
        b) prenatal exposure to alcohol and other substances,
        c) risk of expulsion or exclusion from early learning environments, and/or
        d) the presence of other environmental stressors (i.e., domestic violence,
           poverty, caregiver mental illness, homelessness).

     The children have a DC:0–3R 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
                     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
           Outcome Study Measures
  Domain               National Evaluation                     Additional EC Measures
                 Caregiver Strain Questionnaire          Parenting Stress Index (PSI)
                 (CGSQ)
Parenting/
                 Caregiver Information Questionnaire     Center for Epidemiology Depression Scale
Family Context
                 (CIQ)                                   (CES-D)
                 Family Life Questionnaire (FLQ)         Addictions Severity Index (ASI)

                 Living Situations Questionnaire (LSQ)

Trauma                                                   Traumatic Events Screening Inventory
Exposure                                                 (TESI)
                 Child Behavior Checklist (CBC)          Brief Infant-Toddler Social Emotional
Social/                                                  Assessment (BITSEA)
Emotional
                 Vineland Screener (VS)                  Devereux Early Childhood Assessment –
Challenging
                                                         Social Emotional (DECA-SE)
Behaviors
                 Columbia Impairment Scale (CIS)

Emotional                                                Temperament and Atypical Behaviors
Regulation                                               Scale (TABS)
School           Educational Questionnaire (EQ)          Early Care and Education Stability Scale
Experience                                               (ECES)
Findings
System of Care Community

System of Care Community (n = 728)
New London Building Blocks (NLBB)     21.8%

Rhode Island Positive Educational     21.2%
Partnership (RIPEP)
Sarasota Partnership for Children's   57.0%
Mental Health
           Demographics (n=728)
Gender
Male                         73.5%
Female                       26.5%
Average Age at Intake       4.64 years
Age Distribution
< 1 year                      2.7%
1 year                        3.8%
2 years                       9.1%
3 years                      15.2%
4 years                      17.3%
5 years                      17.7%
6 years                      11.3%
7 years                      11.3%
8 years                      11.5%
        Demographics, cont.

Race/Ethnicity (n = 701)
American Indian or Alaska Native       1.1%
Black or African American              22.1%
White                                  60.0%
Other                                  12.3%
Hispanic/Latino Background (n = 701)
Yes                                    16.8%
Custody Status




       N=370
Referral Source
     (n=708)
Presenting Problems
        (n=427)
Presenting Problems Reported for
    Young Children (n=465)
        Educational Information

Attended an early childhood program in the last   82.5%
6 months (6 and younger; n=275)
Have an IEP (n=207)                               42.0%
IEP is for Behavioral Health Issues (n=87)    75.6%
School Disciplinary Issues in the 6-months Prior to
Enrollment (n=210)
Suspended                                         14.8%
Expelled                                          2.9%
Suspended and Expelled                            1.9%
                 Health History
Children who have:
Have a primary care physician (n=373)                95.4%
Recurring health problem (n=373)                     38.9%
On medication for recurring health problem (n=370)   23.3%
Hospitalized in past 6-months for recurring health   2.8%
problem (n=351)
         Family Characteristics
Children live in homes with:
Other children                 M=1.43
Adults                         M=1.86
Family Income:
Below Poverty                  58.1%
At or Near Poverty             15.6%
Above Poverty                  26.3%
Caregiver Employment:
Worked in last 6-months        58.5%
Hours worked per week          M=31.9
        Child and Family Risk Factors
Caregivers Reported:
Family history of depression (n=356)                     68.8%
Family history of mental illness (n=358)                 46.6%
Family history of substance abuse (n=363)                52.3%
Has the child ever:
Witnessed domestic violence (n=363)                      38.0%
Lived with someone who is depressed (n=361)              62.6%
Lived with some with a mental illness (n=358)            45.2%
Lived with someone convicted of a crime (n=362)          36.7%
Lived with someone w/a substance abuse problem (n=362)   39.2%
Been physically abused (n=359)                           9.7%
Been sexually abused (n=355)                             3.9%
Run away (n=367)                                         9.5%
Talked about suicide (n=373)                             9.7%
Attempted suicide (n=365)                                1.9%
Services Received Prior to Enrollment
Any Service                  32.4%
Outpatient Services          31.0%
School-based Services        23.4%
Day Treatment                2.9%
Residential Treatment        2.2%
Substance Abuse Treatment    --
Preliminary Results from Longitudinal
           Outcome Study
                 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 family’s home or another
    location
           Outcome Study Measures
  Domain               National Evaluation                     Additional EC Measures
                 Caregiver Strain Questionnaire          Parenting Stress Index (PSI)
                 (CGSQ)
Parenting/
                 Caregiver Information Questionnaire     Center for Epidemiology Depression Scale
Family Context
                 (CIQ)                                   (CES-D)
                 Family Life Questionnaire (FLQ)         Addictions Severity Index (ASI)

                 Living Situations Questionnaire (LSQ)

Trauma                                                   Traumatic Events Screening Inventory
Exposure                                                 (TESI)
                 Child Behavior Checklist (CBC)          Brief Infant-Toddler Social Emotional
Social/                                                  Assessment (BITSEA)
Emotional
                 Vineland Screener (VS)                  Devereux Early Childhood Assessment –
Challenging
                                                         Social Emotional (DECA-SE)
Behaviors
                 Columbia Impairment Scale (CIS)

Emotional                                                Temperament and Atypical Behaviors
Regulation                                               Scale (TABS)
School           Educational Questionnaire (EQ)          Early Care and Education Stability Scale
Experience                                               (ECES)
    Risk Factors and CBC Analysis
• Predictors (Risk factors):
  – number of different types of trauma events
  – maternal depressive symptoms
  – parenting stress (total scale)

• Controlled for: child’s age and child’s gender

• Outcome: CBC total problems score at baseline, 6-,
  and 12-months
   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
Protective Factors and CBC Analysis

• Predictors (Protective factors):
  – DECA: Initiative, self-control, attachment

• Controlled for: child’s age and child’s gender

• Outcome: CBC total problems score at baseline,
  6-, and 12-months
  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
                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
Translating Research into Practice:
Imminent Risk and a Public Health
   Approach to Early Childhood
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
      children’s 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.
         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
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
                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.
      Resilience-Informed Approach
• Combination of high risk-status and inadequate
  protective factors compound to intensify the detrimental
  effect on a child’s 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.
           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.
Validation of the DC 0-3R
        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.
         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 Criteria––Preschool 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.
  Purpose of the Diagnostic
Classification: 0-3R (DC:0-3R)
• 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)
      DSM–IV Axis I & II Diagnoses
                                Children 4-8 Years of Age
        Diagnosis (n = 277)                                                                                                         %
        Attention Deficit/Hyperactivity                                                                                        30.3%
        Adjustment Disorders                                                                                                   27.8%
        Disruptive Behavior Disorders                                                                                          19.5%
        Anxiety Disorders                                                                                                      10.1%
        PTSD                                                                                                                    8.7%
        Oppositional Defiant Disorder                                                                                           7.6%
        Mood Disorders                                                                                                          6.9%
        Pervasive Developmental Disorders                                                                                       6.1%
        Other                                                                                                                   9.1%

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).
    DC:0-3R Axis I Diagnoses
                      Children 0-3 Years of Age
Clinical Diagnosis (n = 97)                                                                                   %
Adjustment Disorders                                                                                      32.9%
Anxiety Disorders                                                                                         14.4%
Sensory Stimulation-Seeking/Impulsive                                                                     13.4%
Hypersensitive                                                                                            12.4%
Regulation Disorders                                                                                       7.4%
Mixed Disorders of Emotional Expressiveness                                                                4.1%
Sleep Disorders                                                                                            4.1%
PTSD                                                                                                       2.1%
Other                                                                                                      6.1%



        Because children/youth may have more than one diagnosis, percentages for diagnoses may sum to more than 100%.
     DC: 0-3 R Diagnosis                   ICD-9-CM Diagnosis
220     Anxiety Disorders
        of Infancy and Early
        Childhood


221     Separation Anxiety     309.21       Separation anxiety disorder
        Disorder
222     Specific Phobia        300.29       Other isolated or specific
                                               phobias
                                            Acrophobia, animal phobias,
                                               claustrophobia, or fear of
                                               crowds
223     Social Anxiety         300.23       Social phobia
        Disorder (Social                    Fear of eating in public, speaking
        Phobia)                                in public, washing in public
224     Generalized Anxiety    300.02       Generalized anxiety disorder
        Disorder
225     Anxiety Disorder       300.00       Anxiety state, unspecified
         NOS
     DC: 0-3 R Diagnosis                ICD-9-CM Diagnosis

430   Sensory Stimulation-   314.01   Attention deficit disorder with
      Seeking/Impulsive               hyperactivity
                                            Combined type
                                            Overactivity NOS
                                            Predominantly
                                             hyperactive/impulsive type
                                            Simple disturbance of
                                             attention with overactivity
                             314.1    Hyperkinesis with
                                      developmental delay
                                            Developmental disorder of
                                             hyperkinesis
                             314.9    Unspecified hyperkinetic
                                      syndrome
                                            Hyperkinetic reaction of
                                             childhood or adolescence
                                             NOS
                                            Hyperkinetic syndrome NOS
                             313.9    Unspecified emotional
                                      disturbance of childhood or
                                      adolescence
                                        Sensory Stimulation-
Demographics            Anxiety         Seeking/Impulsive
Gender
Male                    50%             86%
Female                  50%             14%
Average Age at Intake   4.7 years       4.3 years
Age Group
Girls                   3.7-5.8 years   2.8 years
Boys                    4.5-4.7 years   2.8-5.3 years
Race
Black or African        25%
American
White                   75%             86%
Multi-Racial                            14%
Hispanic/Latino         50%             29%
Background
     Average Scores of Child Behavioral and
     Emotional Problems for Children Ages
               1½ to 5 at Intake
                                                                         CBCL 1½-5
                                                                         Average
                                    Borderline                           Syndrome Scale
Measure                             Clinical               Clinical      Score
Anxiety
Anxious/Depressed T-Score           25%                    25%           64 (Range 59-79)

Attention Problems T-Score          0%                     0%            58 (Range 50-60)
Sensory Stimulation-Seeking/Impulsive
Anxious/Depressed T-Score   14%                            14%           62 (Range 50-74)

Attention Problems T-Score          57%                    29%           68 (Range 57-73)

         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.
Looking Toward the Future
                    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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