Addressing Infant/Toddler Mental Health in Tennessee

Frances DuranFrances DuranNational Technical Assistance Center for Children’s Mental HealthNational Technical Assistance Center for Children’s Mental HealthGeorgetown University Center for Child & Human DevelopmentGeorgetown University Center for Child & Human Development

September 26, 2011September 26, 2011

For Discussion Today…

Why is early childhood mental health important?

How can we fund services and supports for infants and toddlers?

How can we build workforce capacity in this area?

Why is Early Childhood Mental Health Important?

Early childhood mental health is

a young child’s ability to…

LAUGHLOVE

LEARN

(In the words of renowned infant psychologist Alicia Lieberman)

Estimated PrevalenceBetween 4 and 10% of all young children have clinically significant emotional and behavioral challenges (Center for Mental Health in Schools, 2005)

Children who are poor are much more likely to develop behavior problems with prevalence rates approaching 30% (Qi & Kaiser, 2003)

Societal Benefits of Intervening EARLY

Reduced use of special educationIncreased high school graduation & college attendance ratesReduced use of welfare Reduced crime and contact with criminal justice system

(Karoly, Kilburn & Cannon, 2005)

Benefit-Cost Ratios: ExamplesNurse Family Partnership: 5.7 ($41,419 / $7,271)– Home visiting for low-income first-time mothers– Focuses on improving pregnancy outcomes, mother’s self-

efficacy, and parenting skills – Prenatal to age 2 (Karoly, Kilburn & Cannon, 2005)

Parent Child Interaction Therapy: 3.6 ($4,724 / $1,296)– Live coaching format (therapist to parent)– Focuses on improving parenting interaction and helping child

develop a secure attachment to the parent(s)– Ages 2 to 8 (Aos, Lieb, Mayfield, Miller & Pennucci, 2004)

How do we foster positive early childhood mental health?

Promote the behavioral/emotional well-being of allStrengthen the well-being of children and families at riskEnsure access to services for those with atypical developmentHelp families address their own barriersExpand competencies of non-familial caregivers (e.g., child care providers)

Jane Knitzer

Assessments for Infants and Toddlers

Issues: – Reluctance to refer children so young– Impact of environmental/family issues on infants/toddlers overlooked >

missed opportunity for assessment

Diagnostic Tool: DC: 0-3R (Zero to Three)Provider Reimbursement: Crosswalk to DSM:IV and/or ICD:9-CM Resources– “Developing a DC:0-3R Crosswalk” and “DC:0-3R: Crosswalk

Development and Use in Professional Development and Reimbursement” Available at: www.zerotothree.org

– Example: Florida’s CrosswalkAvailable at: www.thefloridacenter.org/pdfs/Fl_Crosswalk_June_2010.pdf

Interventions forInfants and Toddlers

Issues– Dyadic nature of the work can be hard to fund– Reluctance by some to diagnose infants/toddlers– Few evidence-based practices for this age group– Lack of providers trained in infant/early childhood mental

health

Provider Reimbursement for Infant/Toddler Interventions

General Strategies:– Braid/pool funding– Maximize Medicaid (seeking policy/regulatory

changes as needed)

Resources:– Matrix of Early Childhood Mental Health Services and

Supports in Social and Emotional Health in Early Childhood (Perry, Kaufmann & Knitzer, 2007)

– Early Childhood Mental Health Services: Financing Map

Provider Reimbursement for Infant/Toddler Interventions

Example 1: – Funding Source: Medicaid/EPSDT – Process: Draw down funds by identifying a

diagnosis using the DC:0-3R that is billable through EPSDT(e.g., supports “medically necessary”)

Under EPSDT, state Medicaid programs must cover "necessary health care, diagnostic services, treatment and other measures...to correct or ameliorate defects and physical and mental illnesses and conditions." 42 U.S.C. § 1396d(r)(5) Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening-even if the condition cannot be prevented or cured.

Provider Reimbursement for Infant/Toddler Interventions

Example 2: – Funding Sources: Medicaid, county funds, United

Way, private foundations– Process: secure a diagnosis through DC:0-3R then

bill through Medicaid; if child does not have a diagnosis, then county or private funds are used

– Note: state’s Medicaid plan includes provision that you can bill Medicaid in the child’s name, even if the services are provided to the parent - exclusively or jointly

Building a Provider Workforce with I/ECMH Expertise

DC:0-3R– Train-the-trainer model

Identify evidence-based and promising practices that “fit” for your community– Learning Collaborative model– Resource: “The Learning Collaborative Model.” Available

at: www.chdi.org/download.php?id=428– Resource: Scan of Early Childhood EBPs. Available at:

http://gucchdtacenter.georgetown.edu/early_childhood_SOC.html

Building a Provider Workforce with I/ECMH Expertise (cont’d)

Standardize Personnel Competencies– Resource: “California Training Guidelines and Personnel Competencies for

Infant-Family & Early Childhood Mental Health.” Available at: www.ecmhtraining-ca.org/guidelines.html

Pre-service Training/Education– Partnering with higher education

Funding for Capacity-Building Efforts– Partner with TN Early Connections/System of Care

Going Forward: Questions to Consider

How will you increase the number of providers trained to use the DC:0-3R?Will you pursue a crosswalk between DC:0-3R and the ICD:9-CM? What evidence-based/promising practices for infants/toddlers will you pursue and how will you train the provider community on these EBPs?How will you create provider interest in trainings on the DC:0-3R and new EBPs and address provider turnover?What reimbursement options are available to you through your state’s Medicaid Plan?What other funding streams might be of assistance?

ResourcesFinancing

Effective Strategies to Finance a Broad Array of Services and Supports (Louis de la Parte Florida Mental Health Institute, 2007) http://rtckids.fmhi.usf.edu/rtcpubs/hctrking/pubs/briefs/RTCstudy3IBrief01.pdfSocial and Emotional Health in Early Childhood (Perry, Kaufmann & Knitzer, 2007)

– “Strategic Financing of Early Childhood Mental Health Services” – “Spending Smarter: A Funding Guide for Policy Makers and Advocates to Promote

Social-Emotional Health and School Readiness”– Matrix of Early Childhood Mental Health Services and Supports

Funding Early Childhood Services and Supports (Wishman, Kates & Kaufmann, 2001). Available at: http://gucchd.georgetown.edu/72441.htmlFederal Funding for Early Childhood Supports and Services: A Guide to Sources and Strategies (The Finance Project, 2000). Available at: http://www.financeproject.org/publications/fedfund.pdf

ResourcesFinancing (cont’d)

Making Dollars Follow Sense: Financing Early Childhood Mental Health Services to Promote Healthy Social and Emotional Development in Young Children (National Center for Children in Poverty, August 2002). Available at: http://www.nccp.org/publications/pub_483.htmlMaximizing the Use of EPSDT to Improve the Health and Development of Young Children (National Center for Children in Poverty, June 2006). Available at: http://www.nccp.org/publications/pub_665.html A Self Assessment and Planning Guide: Developing a Comprehensive Financing Plan (Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, 2006). Available at: http://www.tapartnership.org/SOC/SOCfinancingResources.php

ResourcesWorkforce Development

“Developing the Work Force for an Infant and Early Childhood Mental Health System of Care” in Social and Emotional Health in Early Childhood (Perry, Kaufmann, & Knitzer, 2007)

Services and SupportsSupporting Infants and Toddlers with Challenging Behavior. Available at: www.challengingbehavior.org/do/resources/documents/rph_supportInfantsToddlers.pdfBeing an Evidence-Based Practitioner. Available at: www.challengingbehavior.org/do/resources/documents/rph_practitioner.pdfEarly childhood mental health consultation – multiple publications (http://gucchd.georgetown.edu)

ResourcesWebsites

Georgetown University National Technical Assistance Center for Children’s Mental Health http://gucchd.georgetown.eduTechnical Assistance Partnership for Child and Family Mental Health www.tapartnership.orgCenter on the Social and Emotional Foundations for Early Learning www.vanderbilt.edu/csefel/ZERO TO THREE http://zerotothree.orgTechnical Assistance Center on Social Emotional Intervention for Young Children www.challengingbehavior.org

ReferencesAos, S, Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia: Washington State Institute for Public Policy.Center for Mental Health in Schools at UCLA (2005). Youngsters’ mental health in schools and psychosocial problems: Where are the data? Los Angeles, CA: Author.Karoly, L.A., Kilburn, M.R., & Cannon, J.S. (2005). Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, CA: RAND Corporation.Qi, C. H., & Kaiser, A. P. (2003). Behavior problems of preschool children from low-income families: Review of the literature. Topics in Early Childhood Special Education, 23, 188-216.

For More Information

Frances DuranNational Technical Assistance Center for Children’s Mental HealthGeorgetown Universitybazazf@georgetown.edu