Maternal Depression Report

7/29/2019 Maternal Depression Report

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Zero to three

research to policy project:

Materal Depreioad Early Cildood

FULL REPORT

April 2011


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Childrens Deense Fund Minnesota 2 www.cd-mn.org

Tabe o Contents

Executive Summary ........................................................................... 3

Part I. Research Findings in

Maternal Depression and Early Childhood ......................................... 6

Part II. Implications o Research or Minnesota Policy ..................... 16

Part III: Minnesotas Current System and

Options to Decrease the Prevalence and Impact o

Maternal Depression in Minnesota .................................................. 20

Public Awareness .................................................................... 21

Eective Screening and Reerral to Services ............................ 24

Family-Focused Two-Generation Programs .............................. 30

Family Strengthening and Support Programs ........................... 37

Shared Vision and Plan ........................................................... 41

Accountability ......................................................................... 43

Conclusion ..................................................................................... 48

Endnotes ........................................................................................ 50

Te Childrens Deense Fund Minnesota Zero to Tree Research to Policy Project is part o the

Minnesota Community Foundations Project or Babies. Contact Marcie Jeerys, Policy

Development Director at [email protected] or 651-855-1187 or more inormation.


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www.cd-mn.org 3 Childrens Deense Fund Minnesota

Executie Summar

Key Research FindingsResearch across a variety o disciplines is illuminating the pathways through which people arrive at

well-being in adulthood. Increasingly, the research is pointing to the importance o the earliest years

o lie as the oundation or all that ollows. A major area o research is the impact parental mental

health, especially maternal depression, has on very young children.1 Both mothers and children suer

when depression is unaddressed.Depression raises stress hormones to toxic levels in both mother and child and can aect mothers

capacity to nurture and meet their childrens basic care needs. It may have lielong consequences or

the childs relationships with his or her parents and others in their lives. I not addressed, children

o depressed parents are more likely to all behind their peers across an array o developmental areas,

including cognition, socialemotional, physical and mental health. Tey are at higher risk or

needing special education in school, being involved in juvenile justice in adolescence and developing

mental heath and health problems in adulthood.

Research is also determining that maternal depression can be eectively treated or prevented, and its

impact on children lessened or averted, i it is identied and addressed early. o be most eective,

it must embrace a two-generation approach that attends to the mother-child relationship, as wellas the mothers mental health and the childs development. Research is also determining the critical

role other adults can play in an inants development, including paternal depression and child care

providers depression. Many system barriers exist to amilies obtaining needed services, especially lack

o health insurance, culturally appropriate services and problems nding or getting to services.

Tere are buering actors that can reduce the impact o maternal depression on young children,

including amily nancial security, involved and engaged extended amily members and parents with

more education.

Implications or Minnesota

Approximately one in ten new mothers in Minnesota experiences serious depressive symptoms in

the year o her childs birth. Tis translates to approximately 14,000 mothers and newborns in 2009

experiencing the consequences o depression. While women at all income levels and backgrounds

experience maternal depression, some women are more at risk than others including those with a

history o depression and those who are poor, single, or young.

In Minnesota, women at highest risk are those with incomes below $15,000, Arican American

or American Indian women, or those with less than or equal to a high school degree. Families in

the states public assistance programs are particularly at-risk or experiencing the negative impact


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o mental health disorders. Forty-our percent o the caregivers in MFIP amilies had a diagnosed

mental health disorder in the last three years; 53% o caregivers in MFIP child-only cases have a

diagnosed mental health disorder. Tis high rate o mental illness-most oten depression-combined

with the large number o children under three whose amilies receive MFIP means that many o the

children most at-risk o experiencing developmental delay could be identied and served through

early intervention programs in a cost-eective manner.

Maternal depression in early childhood exacts not only high personal but also high public costs. It

is estimated that the annual cost to society o each untreated mother with maternal depression inMinnesota is at least $23,000. State spending, however, is heavily tilted away rom prevention and

early intervention services. Instead, most public unds are spent on deeper-end services, provided

ater problems that could have been averted have developed. For instance, twelve percent o the

education budget is spent on special education, compared to less than 1% on early intervention

services. Some state policies, such as the reeze on assistance or amilies with newborns, likely

exacerbate the strains that lead to depression.

Current Policies and Options

To Reduce the Incidence and Impact o Materna Depression on Ear Chidhood

Tere is growing awareness o the importance o early childhood in Minnesota, and the impact oparental mental health on childrens well-being. Multiple planning and study eorts are underway

involving representatives rom a wide range o interests and groups. Child advocates, policy makers,

program administrators, researchers and providers across a wide range o programs and services are

increasingly calling or more attention to the early years in a childs lie.

A review o research and program evaluations suggests that to continue this momentum and

eectively reduce the incidence o maternal depression and its impact on Minnesota, the ollowing

elements should be in place:

Public awareness o the symptoms o maternal depression and ways to get help,

Eective early identication o those at risk through screening & reerral practices in both

health and non-health care settings,A two-generation approach to services that addresses the whole amily, especially mother and

child,

Policies that reduce nancial stress on amilies,

A statewide vision and strategic plan that cuts across state agencies and policy silos to provide

a coordinated approach to holistically addressing these issues, and

A system o inormation collection and reporting that inorms practice at the client level and

planning and accountability at the state level.

Minnesota has parts o an eective response already in place. Tis includes requiring health

care providers to give new amilies inormation about maternal depression and how to get help,

reimbursing health care providers in the states public health care programs or depression screening

during well-child check-ups or inants up to age one, and reimbursement or developmental

screening o children. Te state also has many early childhood, adult and childrens mental health

programs and experience with pilots demonstrating the eectiveness o early intervention and

services or children at risk o not being ready or school. Requirements are already in law or

assuring some o the most vulnerable children-that is, children who have been determined to have

been abused or neglectedare reerred or and can receive early intervention services and many

individual providers are making strides in incorporating attention to parents mental health in early

childhood programs, or in addressing childrens well-being in programs targeted primarily to their

adults.


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However, none o these eorts are implemented ully or statewide. Children o parents with some o

the highest rates o depression-those in amilies participating in the Minnesota Family Investment

Programare nearly invisible in that program. Adult mental health services rarely incorporate

attention to children in their intake, treatment and discharge planning. Few data are available on

the extent to which screening and reerral or more assessment or treatment occurs, especially within

the health care system. Tose most at risk or experiencing depression (such as women o color and

low income mothers) are least likely to report they received inormation about maternal depression

as part o their pre or postnatal care. At the state level, data and responsibility or the programs and

issues that aect programs and policies in maternal depression and early childhood are spread acrossthree state agencies with ew institutional supports or collaboration. No entity is specically charged

with reducing maternal depression and its impact on early childhood.

An eective response at the policy level must encourage and support a philosophical shit to a more

holistic, two-generation perspective. Policies should recognize that many adults struggling with

mental health issues are also raising children, and many o the children alling behind their peers

are being raised by parents challenged by mental health and associated issues. Tis means increased

collaboration and communication across programs, public agencies and disciplines.

o assure depression can be identied and eectively treated early, all new mothers and their inants

need uninterrupted access to health care until the child reaches at least age 2. Other options include

ensuring young children o parents who are depressed are eligible or and receive early interventionand other preventive services such as Help Me Grow, Early Head Start, quality child care, and home

visiting.

A long-term solution or reducing the incidence o depression includes addressing the broader

context within which depression occurs. Te signicant role that the emotional and nancial strains

o poverty impose should be considered in reviewing state policies. Options include improving the

capacity o the MFIP program to support poor amilies as well as reviewing other economic policies,

such as unemployment insurance and minimum wage, to help more amilies move out o poverty.

Steps to improving Minnesotas response include a strategic plan that addresses the multiple agencies

and policies that aect these amilies, improved data or planning, practice and tracking purposes

and clear points o responsibility or overseeing the states response.

Virtually all parents in Minnesota want what is best or their children. Maternal depression is an

avoidable barrier that sometimes gets in the way o parents capacity to obtain that or their children.

Part I o this report summarizes the major research ndings on maternal depression, its eects on

children, current treatment and related policies. Part II applies the research to Minnesota and looks

at issues specic to the states population. Part III sets out the components o an eective response in

more detail including the states current policies and practice, promising pilots and best practice in

Minnesota and other states, and specic options to improve the states response.

Despite depressions negative impact on children and its sustained

individual, amily and societal costs, it is perhaps one o the most eectivelytreated psychiatric disorders, i recognized and treated early in its onset.2

National Research Council and Institute o Medicine


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Part I. Research Findins in MaternaDepression and Ear Chidhood

Te inormation below is based on summaries and studies published in peer-

reviewed scientic journals, research institute brieng papers, program evaluation

reports, state survey and program data, and presentations rom and conversations

with Minnesota experts and practitioners. It represents just a small portion o theavailable research.

Finding #1

State sure data indicate that approximate one in ten new mothers in Minnesota experiences maor

depressie smptoms within the rst ear o her babs birth. This is consistent with nationa research

estimates, and represents approximate 15,000 Minnesota mothers and inants experiencin the

eects o materna depression each ear.

Maternal depression reers to depression that occurs during motherhood, which is a time o increasedvulnerability to psychological stress. Depression can develop in the prenatal period (i.e., during

pregnancy), during the postpartum period (generally up to one year ater birth) or in the ollowing

months and years. Depression that occurs during pregnancy or in the rst year ater delivery is

reerred to as perinatal depression.

For a new mother, the drive, energy and enjoyment needed to build and maintain positive amily

relationships recedes.3 I unaddressed, it is more likely to recur. Te symptoms o perinatal

depression are generally the same as those or depression occurring at other times in lie. Tese

symptoms include low mood, eelings o guilt and worthlessness, irritability, diculty concentrating,

loss o energy, anxiety, sleep and appetite disturbances, and, in more severe cases, hopelessness and

suicidal thoughts.4 Providers who work with mothers observe that the additional strain and atigue

accompanying caring or a newborn and the hormonal changes accompanying childbearing give

postpartum depression some unique qualities.

In the context o parenting, depression can be dened as a combination o

symptoms that interere with the ability to work, sleep, eat, enjoy and parent

and that may aect all aspects o work and amily lie...5

National Center or Children in Poverty

Depression can be mild, moderate or severe. Perinatal depression o any severity aects children.

It is dierent rom the baby blues, a non-pathologic condition that aects up to 80% o all new


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mothers and oten includes tearulness, atigue, insomnia and a eeling o being overwhelmed. While

the baby blues typically resolves within two weeks, approximately 10%20% o women continue to

have symptoms o depression or weeks or even months.6

Te chart below shows how an annual sample o new mothers in Minnesota, on average three and a

hal months ater their babys birth, responded to two questions oten used to screen or depression:

Since your new baby was born, how oten

(1) have you elt down, depressed or hopeless, and

(2) have you had little interest or little pleasure in doing things?

Based on the PRAMS rates, out o approximately 70,000 births in 2009, 2,300 women elt

depressed, hopeless and have little interest in doing things all or almost all o the time. Another

5,000 eel down or depressed or have little interest in doing things oten or always. More than

20,000 new mothers eel this way sometimes

in the year ollowing their childs birth.

Other mental health disorders that can

occur around a babys birth with serious

consequences or mother and child include

severe anxiety, obsessive-compulsive

symptoms, and post-traumatic stress

reactions, sometimes triggered by a dicult

birth or past or present interpersonal violence.

Tese conditions can occur simultaneously

with depression.8 Postpartum psychosis,

which requires immediate treatment, occurs

in approximately 12 out o every 1,000

births, usually within two weeks ater

birth. Mothers experiencing postpartum

psychosis may experience delusional belies

or hallucinations instructing them to harmthemselves or their babies. Without eective

intervention, this small group o very high

risk mothers may kill their babies and commit

suicide as well.

... the best available evidence

suggest[s] that perinatal depression, whether major or minor depression, is

a very common complication o pregnancy. Furthermore, and arguably more

important, ater labor and delivery this dramatically common complication,

rather than primarily aecting one individual, now directly aects two:

mother and child.9

RTI-University o North CarolinaEvidence-Based Practice Center

A growing body o research is documenting that some athers also experience depression around their

childs birth that can negatively impact their childrens development.10 Rates o paternal depression

are similar-approximately one in ten. It is generally under recognized, despite the substantial impact

it can have on amilies. Fathers are somewhat more likely to be depressed when mothers are also

depressed. Te mental health o other signicant people in childrens lives can also impact their well-

being. Child care providers in low income and non-subsidized child care centers are also more likely

to suer depression than other women, with negative implications or the children in their care.

Rarely / Never

59.5%

Sometimes30.7%

Often / Always

9.8%

Minnesota Mothers Reporting

Depression Symptoms, 2008

Data Source: Minnesota Department o Health,

PRAMS, 2010.7


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Finding #2

Some mothers are much more at risk or experiencin depression than others, due to compex

interactions o biooica, enetic, interpersona and ie circumstances.

Women with a personal or amily history o depression or other mood disorders are at higher risk

or experiencing maternal depression.11 Refecting the multi-generational eects o depression, many

depressed parents were raised by depressed parents. In those who are vulnerable, major lie stressors,

including the trauma o a dicult birth or the challenges o caring or a newborn, can triggerdepressive episodes.

Also at higher risk o experiencing maternal depression are women with limited social support,

including poor, single, and young mothers. Maltreatment in childhood also increases the risk or

developing major depression. Tese risk actors combine and interact to multiply the odds o being

depressed.12

PMD [Perinatal Mood Disorder] is reerred to as a biopsychosocial problem.

Biologically, hormones seem to play a part in the onset and presentation o

the illness. Sometimes women can develop a thyroid problem postpartum,

or may have a genetic predisposition to depression. Neurochemically, it

appears that women with PPD suer rom a neurochemical imbalance, mostoten involving the neurotransmitter serotonin. Psychosocial issues are also

important. These include the new inant-mother relationship, changes in the

marriage, impact on other amily members and career and work issues. 13

From the State o New Jersey, Speak Up

When Youre Down public education website

As the data in the table below indicate, many o the women most at risk can oten be identied

beore they give birth.

Sources: Helen Kim, 2010; National Center or Children in Poverty, 2008

All women 1020%

History o major depression 3050%

Depression during pregnancy 50%

History o bipolar disorder 50%

History o postpartum psychosis 8090%

Low-income status 4060%

Teen parenthood 4060%

Risk o developing Postpartum Depression

or Other Mood Disorders14,15


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Finding #3

A stron association between poert and depression exists in the U.S., as we as oba, athouh

women at a income ees experience depression.

Depression is oten viewed as a disease o poverty.16 Poverty oten brings with it many other

challenges including social isolation, economic and educational disadvantage, intimate partner

violence, poor health and problems with anxiety or substance abuse. Heightened levels o the stress

hormone cortisol, which is associated with depression, are also ound at high rates in people living inpoverty.17

Poverty and depression have bidirectional eects.18 Te stress o living with ood insecurity in

substandard housing and unsae neighborhoods can trigger depression; and depression can make it

harder (psychologically and materially) or people to cope or nd their way out o these circumstance

Low socioeconomic position is the source o a host o chronic stressors.19


Depression oten co-occurs with substance abuse, as parents try to sel-medicate, and is more

requently observed in women experiencing intimate partner violence. One study o amilies in

poverty ound that mothers who were poor, physically abused and severely depressed were more likelyto abuse alcohol than poor mothers who were physically abused and not depressed (see chart below).

Like poverty, substance abuse and amily violence are associated with social isolation. Tese actors

compound the negative impact o maternal depression and economic deprivation on adults and

children.

Nine-Month-Old Babies Living in Poverty More Likely

to Experience Additional Risks when Mother Is Depressed

Source: Urban Institute, 201020

Many low income women view depressive eelings as just part o everyday

lie.21 National Center or Children in Poverty

0Severely depressed

motherNot depressed

mother

P

ercent

5

10

15

20

Motherphysicallyabused

Mother had4 or moredrinks in onesitting


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In Minnesota, the annual survey o new mothers (PRAMS) consistently nds a close relationship

between income and maternal depression. Mothers with annual incomes less than $15,000 report

severe depression symptoms at more than three times the rate o mothers with yearly incomes o

$50,000 or more.

Postpartum Depression by Income, Minnesota 2008

Source: Minnesota Department o Health, 201022

Depression during or ater pregnancy is associated not only with low income, but also with being a

young mother, being Arican American or American Indian, and/or having a high school education

or less. Women indicating they were o Hispanic origin in the survey were more likely to report

depressive symptoms than white mothers (12% vs. 8%) but were substantially less likely than Arican

American (18%) or American Indian (16%) mothers to report depressive symptoms.23

Demographic Groups Reporting the Highest Rates o PostpartumDepression, Minnesota 2008

Source: Minnesota Department o Health, 201024

0All Under

age 20Age

2024Black Amer.

Indian< Highschooleduc.

Highschool


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It is important to note, however, that most low income mothers are not depressed, and many

children raised in poverty successully overcome their odds. Te act that the majority o people

living even in squalid poverty remain well, cope with the daily grind o existence and do not

succumb to the stressors they ace in their lives...[is]...the real challenge or public health researchers;

to identiy the protective qualities in those who do not become depressed when aced with awul

economic conditions.25

More education and social support are two o the major actors observed to decrease the likelihood

o depression in poor mothers in the U.S. and other countries.

26

Some cross-cultural researchindicates that maternal depression is less prevalent in societies with more extended amilies and more

supportive birthing practices. Children can be buered rom the eects o poverty i the maternal-

child attachment is strong.27

Finding #4

Depression diminishes parents abiit to nurture their inants.

Mothers who are depressed have a harder time responding to their inants cues and cries or

attention in a nurturing manner. Tis is hard on both the mother and the newborn. Depressed

mothers may withdraw emotionally rom their inants and be unresponsive to their babys cries or

smiles. Tey may ail to return their newborns gaze and take little pleasure in their babies, insteadmisreading or ignoring their inants cues, and over- or under-stimulating their babies in response. 28

Depressed mothers are also less likely to read books, sing songs or tell stories to their children.

Some depressed parents react irritably or in a hostile manner or prolonged periods o time to their

children. Tey may be easily provoked to anger, lack empathy and demand reactions that their

children are developmentally incapable o producing. Tese parents may express negative attitudes

toward their babies, or instance, attributing anger to their inants cries or labeling their babies as

bad. Some depressed parents exhibit both patterns o parenting, responding in ways unpredictable

to their inants.29

Depression can also impair a parents ability to ulll the management unctions o parenthood.

Mothers experiencing depression are less likely than nondepressed mothers to breasteed, ollowsaety practices (e.g., put children in proper car seats, or cover electrical sockets), ollow preventive

health advice or their children or adequately manage their childrens chronic health conditions

such as asthma. In turn, the additional care burden caused by low birth weight and other birth

complications that occur more requently in births to depressed mothers can also overwhelm

depressed mothers once their children are born, resulting in higher medical neglect and abuse rates

or these children.30

A national longitudinal study o amilies involved in child protection ound high rates o depression

and high levels o clinical need. Over a ve-year period, 46% o the parents o young children

involved with the child welare system reported depressive symptoms. Many caregivers reported

recurring depression. Domestic violence was highly correlated with depression in these amilies.31

Te research on athers experiencing depression ater their childs birth also shows negative

interactions between parent and child. Depressed athers were more likely to spank their one year old

children and were less likely to read books to them.32

For some children, growing up with a depressed parent means a childhood o negative and

unpredictable parental behaviors, irritability, and inconsistent discipline, requently accompanied by

heightened marital confict. It can also mean less supportive parental behaviors-less warmth, praise,

nurturance and mentoring.33 For adults, it means a diminished capacity to enjoy parenting and

amily lie.


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Finding #5

The harmu eects o unaddressed depressed parentin can compromise chidrens heath

deeopment at seera points, startin beore birth. The eects are transmitted biooica and

enironmenta and resut in hih persona and pubic costs.

Te impact o maternal depression is especially great prenatally and during early childhood. Tese

are periods o especially rapid brain growth as the neural circuitry in the brain is being developed

in a step by step progression.34 It is during these years that children are most dependent on theircaregivers. Tey begin to learn how the world works rom their parents responses.

Maternal depression and anxiety is a stronger risk actor or child behavior

problems than smoking, binge drinking and emotional or physical domestic

violence.35

National Center on Children in Poverty

Babies o depressed mothers are more than three times as likely to be born prematurely, and our

times as likely to be born at low birth weight or with birth complications.36 Tis is due to both the

high levels o stress chemicals produced by their mothers, and poorer sel-care during pregnancy.37

Beore they are born, their mothers heightened cortisol levels can aect the development o their

stress response and immune system. Ater birth, they may continue to have high cortisol levels withlielong eects, including higher rates o chronic diseases in adulthood as a result o damage to

multiple organs and systems rom heightened cortisol levels.

In inancy, the toxic stress levels in both mother and baby may also make their relationship more

challenging. Dicult babies whom mothers have a hard time consoling oten exacerbate maternal

depression. Tese babies, in turn, are more vulnerable to the eects o depressed parenting.

Te dynamics o depressed parenting can also be observed behaviorally. Nurturing parents let babies

know someone will respond when they are upset and need comorting, or are hungry and need ood.

Parents who respond appropriately to their young children coner predictability, stability and a sense

o security rom which the inant gradually learns emotional and behavioral sel-regulation.38

Inants and toddlers whose parents are depressed, however, oten ail to get these supportive

messages. In response to a mothers hostility or indierence, an inant may turn away to limit

her intrusiveness and internalize activity.39 As a result, the inant may be less likely to develop the

condence necessary to explore and learn through his or her environment.40 Because their mothers

do little to support their early attempts at exploring and communicating, they are unable to cope

and become passive and withdraw. Some exhibit signs o clinical depression as early as preschool age.41

Children o depressed parents are at great risk or depression and

maladjustment in academic, social and intimate roles ...42

National Research Council and Institute o MedicineDuring their school years, these children oten have poorer mental, motor, and language skills

development, less capacity to concentrate; ewer abilities across a broad spectrum o emotional skills;

more negative response to their environment; and more behavioral diculties than children o

nondepressed mothers.43 Tey are more likely to exhibit attention and hyperactivity disorders during

grade school and their pattern o interacting negatively with others may escalate.44 In addition,

they more requently exhibit aggressive behavior, and have higher rates o asthma, and tobacco and

substance use than children o nondepressed parents. Chronic maternal depression even predicts

cardiovascular problems in adulthood.45


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Sources: Canadian Pediatric Society (2009), Oregon Department o Human Services (2010), National Center or

Children in Poverty at Columbia University (2008)

A variety o longitudinal studies have conrmed the greater likelihood that children with early

childhoods characterized by poverty and associated experiences, including parental depression, will

be involved in increasingly costly interventions through their lie course. Tis includes out-o-home

placement, welare, special education, and juvenile justice. A large-scale study o Kaiser Permanente

health plan enrollees ound that adults who had experienced seven or more adverse childhood

experiences were more than three times as likely to develop range o physical health problems,

including chronic diseases such as cardiovascular disease, diabetes and cancer.49

It is important to note, however, that the research on maternal depression also underscores the

importance o considering the nancially impoverished circumstances in which many children o

depressed parents grow up. Although the relationships between depression and child development,

and poverty and child development have been studied, the associations among these actors and their

interactions are less well-understood. Research does indicate that some actors can protect children

rom the potential harmul eects o their parents depression. Tese protective actors include

avorable amily nancial circumstances, exposure to ewer episodes o maternal depression, andbeing older at the onset o their mothers depression.50

Because o the role these other actors play in determining the impact o depression on children and

amilies, researchers caution that the eectiveness o treatment or depression may be diminished

i parents continue to live in stressul situations, such as poverty, that exacerbate or prolong

depression.51

Despite the documentation o these problems or children o depressed

parents, researchers caution that because maternal depression oten

occurs in the context o poverty, domestic violence and social isolation, the

relationship between depression and parenting is complex and needs to

be considered in the context o a larger set o moderators and mediators,

especially including other parental characteristics and the role o stress and

social support.52


Newborn Ifacy Toddlerood Later Cildood Adolecece

Eample

of Eleated

Cildood Ri

Low birth weight

Preterm birth

complications

Diculty

sel-soothing

Impaired

parent-child

attachment

Behavior

problems

Emotional

problems

Delayed

development o

language

Learning

diculties

Conduct

disorders

Vulnerability to

depression

Depression

Anxiety

disorders

Substanceabuse

Learning

disorders

Potential Impact o Maternal Depression On a Childs Development 46 47 48


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Finding #6

Eectie serices iew materna depression throuh a two-eneration, parent-chid reationship ens.

Practitioners who work with expectant and new parents report that the birth o a child presents a

unique window o opportunity or change. During that time, parents are oten highly motivated

to accept help or their childs sake.53 Tis is encouraging because depression is a highly treatable

disease.54 Up to 80% o women who receive treatment are helped.55 Women are most oten treated

with medication, psychotherapy, support groups or some combination o services.56

Most o theseinterventions, however, do not address the adult as a parent and do not actively include strategies to

prevent or repair damage to the parent-child relationship. Most interventions also stop ar short o

addressing the broader circumstances in which amilies live, and the impact o systems that ail to

address or even increase stress on amilies with ew supports.

reating only the mother oten isnt sucient to help her child. While some studies report substantia

improvement in child unctioning ater mothers are treated, others report many children still

exhibiting problem behaviors.57 I not identied and treated early, negative parent-child patterns

o interactions may be established and persist despite the mothers treatment. Tese detrimental

patterns o parenting and developmental processes may become increasingly dicult to change as

time passes.58 Negative patterns o interaction may also be carried into interactions with other adults

resulting in school behavior problems and dicult relationships in adulthood.

Depression treated in the context o a two-generation model helps parents with their parenting

skills and their depression, and also oers enhanced support or the children.59 reatment begins

by identiying those at risk or already showing its eects. Because ninety-nine percent o babies are

born in a health care setting, and 84% o mothers receive some prenatal care, most current eorts

to identiy depression in mothers or developmental delays in children ocus on health care providers

as the primary gateway to treatment.60 (Research also suggests that health care settings-especially

well-child visits-may also be an appropriate setting to identiy athers experiencing depression. Tis

is because the majority o athers in one study had attended a well-child visit and talked with their

childs health care provider.61)

Studies have determined that standardized screening tools (e.g., sel-report questionnaires) are

more eective at correctly identiying depression than relying on physician judgment alone. Several

scientically validated screening tools exist although even short questionnaires containing two or

three questions have been ound to enhance clinicians ability to recognize depression.62

Not all practitioners screen mothers or depression, though, because the paths to urther care [are]

not clear and accessible.63 Furthermore, a connection is oten not made between a mothers positive

screen or depression and her childs well-being. Similarly, the connection is not oten made between

developmental delays detected in children and possible depression or other mental health disorders

in his or her parent.

Despite the promise o screening programs, current approaches to parentaldepression screening have not been integrated with assessment o parental

unction or child development.64

The National Research Council and Institute o Medicine

Estimates vary, but most parents with depression go untreated. One estimate is that only 15% o

depressed mothers obtain proessional care.65 wo-thirds o new mothers in Minnesota reported they

did not get counseling or help or a variety o problems they experienced during pregnancy or ater

birth.66 A national study looking at mothers in some o the highest risk groups ound less than one-


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third o severely depressed mothers o nine month olds were seeking mental health treatment.67

Reasons or the low rate o women accessing treatment are many. Women or their health practitioner

may not recognize their depression. Tey may not have adequate insurance coverage or they may

have diculty accessing treatment due to the realities o living in poverty (poor transportation,

lack o child care to participate in treatment or inadequate local mental health resources) or with

domestic violence. Many low-income mothers, especially those rom communities o color, distrust

the mental health and health care system, and ear that i they are not seen as good parents, child

welare will come and take their children away.

68

Concerns have been raised about the lack o culturally appropriate mental health services or

immigrants and people o color, and the stigma that surrounds mental illness that oten discourages

help-seeking. Although most practitioners believe depressed parents want what is best or their child,

the bidirectional eects o poverty and depression oten make it dicult or poor parents to take the

initiative necessary to obtain care, especially in a system that contains multiple nancial, eligibility

and cultural barriers to access.

Many proessionals working in the eld believe it especially important or children o depressed

parents to receive stimulation in or outside o their home or a ew hours each day so they can

interact with adults and other children who are not depressed. Tese are the children who oten

show the biggest gains when provided early intervention services and care in high quality child caresettings.69

Parents with severe mental illness and ew resources ace substantial challenges and oten receive little

help with their parenting. As a result, they lose their children to oster care or permanently have their

parental rights terminated at a high rate, even when they might have been able to adequately care or

their children given sucient support.70


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Part II. Impications o Research orMinnesota Poic

Implication #1

At east twent-two thousand oun chidren in Minnesota ie with a mother who experienced serious

smptoms o depression at some point durin the critica rst three ears o ie.71 Een more chidren

are aected when those who are iin with athers or other reaties or receiin chid care rom

depressed aduts are considered.

Most o these amilies have not received help. In Minnesota, two-thirds o the women who reported

they needed counseling or amily or personal problems during their pregnancy did not receive it.72

Tis has implications or their childrens development and uture well-being, the state economy and

society.

Implication #2

Much current spendin can be tracked to pubic sstems aiure to interene ear to preent aderseear chidhood experiences. It is estimated that the ear two-eneration cost to Minnesotas econom

o not treatin each mother with materna depression is at east $23,000.73

Te estimated annual cost o not addressing mothers depression is at least $7,200, based on lost

income and productivity due to their depression. Te annual costs o untreated maternal depression

per child is $15,000, based on the quantiable costs o births to a mother with depression including

preterm delivery, lower birth weight, and reduced uture income due to delayed brain development,

higher risk o death. Although only a small minority o children with adverse childhood experiences

ends up in the criminal justice system, they are more likely than other children to do so and those

costs are included in this estimate. In addition, the annual lost tax revenues rom both mother and

child as a result o the eects o depression are estimated at nearly $400. Some o the eects omaternal depression, including a greater likelihood o needing special education, and chronic health

care costs (including depression) in adulthood cannot be quantied, due to lack o data. As a result,

cost-benet analyses using $23,000 as the cost o untreated maternal depression will underestimate

the benets o treatment.


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Implication #3

Much current state spendin can be tracked to ear chidhood experiences. Approximate one-ourth

o the state budet is spent on specia education, pubic saet, weare, count socia serices and

Medica Assistance basic heath care or amiies. Another amost one-th o the budet is spent on

on term and basic heath care or peope with disabiities and the eder, some o which can be

tracked to inadequate prenata care and aderse ear chidhood experiences.

Some spending or these services is inevitable (e.g., children born with Downs syndrome), but manyo the conditions requiring special education (learning disabilities, speech and language delays, mild

hearing loss, and social-emotional and behavioral maladjustment) could have been prevented or

ameliorated with early intervention.74 Even those children born with conditions with very high rates

o developmental delays such as Downs Syndrome benet rom early intervention services, and can

become more independent and reduce their need or more intense assistance as they age.

Spending on programs aecting children is currently skewed away rom prevention and early

intervention, going instead or deep-end services, provided ater problems have developed and

worsened. Special education makes up 12% o education spending, or instance, while early

childhood programs represent 1% o that budget.75 Similarly, in the child welare system, more

is spent to care or children removed rom their homes than to saely keep amilies together.Furthermore, prevention-oriented programs are oten the rst to be cut to balance budgets.

Te 2009 State Budget rends Commission predicted that i spending on health care is not

restrained over the next decade, it will use up nearly all o the uture projected growth in state

revenues, leaving little room to address issues in the rest o the state budget.76 Although it is not

possible to quantiy the exact contribution o adverse childhood experiences to projected health care

costs, the available research suggests it is a major contributor to current and projected liabilities.77

Implication #4

Careiers in amiies receiin MFIP, aread struin with incomes ar beow the poert ine, asohae hih rates o menta heath dianoses. Both the MFIP and chid weare prorams sere man

amiies with oun chidren. This means that man o the chidren and amiies who are most ike to

benet rom preentie and ear interention coud be identied throuh their participation in pubic

prorams.

Seven out o ten MFIP recipients are children, and children under age three are over-represented in

both MFIP and child welare caseloads. Nearly one-ourth (24%) o children in amilies receiving

MFIP are under age 3.78 More than one-ourth (28%) o the children reported as maltreated in the

child welare system are under age 3.79 Nearly hal o these children are living with caregivers with

serious mental health issues and poverty.

Forty-our percent o the amilies receiving MFIP in 2009 had a caregiver who was diagnosed

with a serious mental health condition in the prior three year period-our times the rate

ound in the rest o the Minnesota population.80 Proessionals in the eld believe the number

is higher but the stigma and diculty many MFIP recipients experience obtaining care

reduces the number actually receiving a diagnosis.

Fity-three percent o the caregivers in child-only MFIP 81 cases receiving disability payments

(SSI) had a serious mental health diagnosis.82


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A large scale pilot project in Minnesota working with amilies reported to Child Protection

but screened out (i.e., not investigated or possible child maltreatment) ound a high rate

o very poor amilies61% had incomes below $15,000)83putting them at high risk or

depression.

Data rom some state pilot projects and special reports conrm that many o the children in MFIP

amilies are already exhibiting developmental and other delays.

61% o the children (3 months to 5 years) screened as part o a pilot project scored positive

or possible cognitive, emotional or behavior delays.

84

Tree times as many children in MFIP child-only relative care as other Minnesota children

have social, emotional or behavioral disabilities.85

Tirty-nine percent o children in out-o-home care in 2007 were identied as having

a disability. Emotional disturbance and developmental delays are the most common

disabilities.86

Children screened by home visitors serving low income amilies (200% FPL or lower) also ound

high rates o delays.

One-third o children screened in 2009 were not meeting developmental milestones; 12%

were not meeting social-emotional milestones.87

Implication #5

The state is not takin u adantae o the opportunities suested b these data to taret preention

and ear interention eorts. As a resut, thousands o parents and their inants each ear are

unnecessari experiencin the aoidabe eects o depression.

Although the occasional studies cited above suggest a high rate o parental mental health concerns

and associated low rates o child well-being in amilies receiving MFIP or involved in the child

welare system, the state does not collect and report these data on a regular basis. Similarly, little

is known about these amilies involvement in programs intended to prevent or address their risks

or developmental delays, e.g., early childhood programs or services, or their outcomes, such as

readiness or kindergarten or graduation rom high school.

At an aggregate level, state data conrm that children rom high risk groups (i.e., low income)

are less ready or kindergarten than other children, and that the gap between them grows as they

age.88 However, this inormation is not used systematically by state systems at an individual child

or amily level to develop plans to help amilies, even though many programs exist in the state with

documented eectiveness in preventing or averting developmental delays in children at high risk

or poor childhood outcomes. Tis suggests that thousands o children and their amilies who are

vulnerable to maternal depression and its impact could be identied within the states database and

oered services to improve their childs school readiness.

In addition, there is little inormation at the policy level to guide legislators and others regarding theeectiveness o the states eorts or to point to uture action.

Minnesota has many resources that could be used to help these children and their amilies, and

avert uture public expenditures. However, as discussed more ully in the next section, the state has

generally ailed to bring its successul pilots to scale or taken ull advantage o ederal unds. Te

service system is still highly ragmented and silo based (refected in the administration at the state

level), and there is still a general lack o awareness o depressions eects and its treatment among

the general populace and many o those working on the ront line o the social services, health and


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mental health care systems. Minnesota is not moving as ast or as ar as some other states have in

ensuring that its youngest citizens who are most vulnerable to the negative impact o their mothers

depression receive help early on.

Implication #6

This is a ood time to chane the traector o state spendin and preent or interene ear

beore probems escaate in amiies and chidrens deeopment. The states budet chaenes and

the momentum that aread exists in Minnesota around these issues can be a sprinboard or the

chanes needed to make substantia proress in improin the we-bein o chidren and amiies.

A good deal o activity is already underway. Tis includes health care and other proessionals already

involved in educating their colleagues on these issues. Tere is an active and nationally recognized

research agenda at the University o Minnesota continuing to study these issues, including the

impact o stress on childrens brain development and eective approaches to maternal depression in a

variety o communities in the state.

Minnesota is also home to some o the leading experts in the psychiatric treatment o maternal

depression as well as several early childhood and child care providers sophisticated in the knowledge

o adult mental health and its impact on children. Proessionals working at both the state andlocal level are spearheading eorts to encourage collaborative eorts within government to address

maternal and child mental health issues. Postpartum depression support groups are available in some

areas o the state, and some providers have joined together to oer specialty support services. A

oundation ocused on increasing awareness o PPD (Jennys Light) is headquartered in Minnesota.

Maternal depression is receiving more attention in home-visiting programs, and providers have

recently ormed a coalition to share inormation and expand awareness o the services they provide.

Tere is also growing awareness o the importance o early childhood in the administration and state

legislature, as well as the child advocacy and child care communities. A coalition o oundations has

as its goal that every child be ready or kindergarten by 2020.

As the magnitude and societal consequences o this problem have beenbetter understood, increasing numbers o clinicians and policymakers

have begun to realize that is unacceptable to ignore what science tells us

and have made the prevention and treatment o maternal depression an

important goal.89

Center on the Developing Child at Harvard University


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Part III: Minnesotas Current Sstemand Options to Decrease the

Preaence and Impact o

Materna Depression in Minnesota

Many o the actions that are needed to improve outcomes or mothers with depression and their

young children do not require immediate changes in policy. In some areas, more study (perhaps

acilitated by legislation) is necessary beore policies are enacted to ensure they will not have

unintended consequences. More can also be learned rom prior assessments o the states early

childhood and mental health systems, and relevant pilot projects that have already been conducted

and rigorously evaluated. Some o these pilot projects had very positive impacts on children and

amilies but have not been brought to scale or received much attention in the broader policy debate.

In some cases, where communities and proessionals are already highly involved, policy changes

may only be necessary to remove barriers or provide incremental help to leverage substantial private

results. More options will also arise rom ongoing activity at the state and local agency levels,

including the Governors Early Learning Council (previously the state Advisory Council on EarlyEducation and Care).

Based on the research conducted or this report, the ollowing components are recommended as

necessary or a comprehensive response to maternal depression and early childhood:

Widespread public awareness o maternal depression and its impact on early childhood, with

targeted messages to those most at risk, and to people who work with at risk amilies.

Eective early screening and reerral or urther assessment or treatment o both mothers and

children at risk or, or already aected by, depression.

wo-generation ocused care, including adult and child mental health services and early

childhood programs that address parental depression and related parenting and child

development issues, with amilies most at-risk o experiencing depression assured access topreventive and early intervention services.

Public policies that reduce nancial-related stressors on amilies.

A broadly shared statewide vision and plan or improved outcomes or amilies and children,

including school readiness, with sucient data or policymakers and state administrators to

measure progress and compliance with state goals.

Clear points o responsibility and accountability within state government or achieving

these goals, with authority to coordinate eorts across government, reinorced by data and

budgeting strategies that encourage eectiveness and eciencies.


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Tese components are discussed in more detail below, including descriptions o

some o the current policies and practices in each area, examples o relevant pilot

projects or policies in other states, and state policy options or continued progress

in each area. Te state policy options are actions that generally require legislative

change or high level administration action. Also presented are options or action

by entities outside o government, such as proessional associations and community

organizations. Te inormation is based on state reports and data, conversationswith practitioners and experts in the eld and state and local agency sta. Tese

options are built on strong policy ootings already in place, thanks to prior reorms

and continuing attention by concerned individuals across the state.

Public Awareness

Eorts to address materna depression wi be most eectie i the are aimed at promotin the

we-bein o a mothers and inants in Minnesota. Within an oera eort to optimize chidrens

heath and menta heath, inormation shoud be taiored and tareted to roups based on their riskor interaction with amiies most at risk. Messaes shoud be cutura appropriate and support a

preentie approach that promotes ear interention at the communit and indiidua ees.

BACkgROUnD

Since 2005, Minnesota law has required hospitals to provide written inormation on postpartum

depression to new parents beore they leave the acility.90 Physicians and others providing prenatal

care must have similar inormation available or women and their amilies. Te Department o

Health is charged with overseeing the policys implementation. Data rom the annual statewide

survey o new mothers (PRAMS) indicate the law has been successul in increasing the rate at which

women receive education about postpartum depression: Between 2002 and 2008, the percentage

o women reporting they received inormation about postpartum depression beore or ater their

babies birth increased rom 77% to 90%. During that period, the percentage o women reporting

depressive symptoms decreased. Although it is not possible to determine a causal relationship, it is

plausible that the inormation has had an impact already.

Did a health care worker talk to you about PPD?

02004 2005 2006 2007

PercentAnswerin

g

Yes

20

40

60

100

80

2008

Source: Minnesota Pregnancy

Risk Assessment Monitoring

System, 2004-200891


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Although awareness among pregnant and new mothers has increased, women in the demographic

groups most at risk or depression are least likely to report receiving the inormation.

Women Most and Least Likely to Report No Health Care Provider

Talked to Them About Postpartum Depression92

Source: Minnesota Pregnancy Risk Assessment Monitoring System, 2008

Other surveys indicate that much o the public, including parents, are unaware o the impact o

their mental health on their children. A national survey ound, or instance, that two-thirds o new

parents did not realize babies are aected by their parents moods and that babies experience eelings

o sadness and ear.93

At the ederal level, Congress recently passed the Melanie Blocker Stokes MOHERS Act, named

ater a mother who killed her inant daughter and hersel. Although no additional money has been

appropriated yet, the ederal law encourages the ederal Department o Health and Human Services

to launch educational campaigns aimed at health care proessionals and the broader public.

OPTIOns TO InCREAsE PUBLIC AwAREnEss

1) Deeop heath promotion messaes tareted at a Minnesotans reardin the

importance o parenta menta heath and ear enironments to chidrens we-

bein.

Locally, a coalition o oundations in Minnesota has pledged nancial support or public education

regarding the importance o early childhood experience to adult well-being. Ensuring the message

includes promoting positive amily mental health and supportive communities could increase itsimpact.94

STATE POlICy: Support a public awareness campaign that educates the general public about amily

mental health and its impact on children.

Demorapic

group

Percet Idicatino Commuicatio Reardi

Potpartum Depreio

American Indian 16%

Hispanic 13%

Black 13%

Not Married 12%

Less than $15,000 income 13%

Receiving public insurance 12%


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New Jersey and Washington State have statewide public awareness

campaigns called Speak Up When Youre Down with hotlines and websites

providing inormation and help or women and others concerned about

maternal depression.

New Jerseys website is:

http://www.nj.gov/health/hs/postpartumdepression/index.shtml

Washingtons website is: http://www.cc.wa.gov/ppd/home.htm

All Minnesotans and their communities should be encouraged to reach out and support new parents

especially those most in need. Social isolation is a major actor in maternal depression and is one o

the reasons it is so detrimental to young childrens social and emotional development. Remembering

that a new parent, especially one that is young, poor or socially isolated rom amily or riends, or

a amily without local support, regardless o their income level, might be in need o support and

riendship is something all Minnesotans could do.

Churches serving Arican American amilies on the North Side o

Minneapolis are supporting young parents who are not reached by

institutional social service agencies in inormal peer-acilitated gatherings

and ormal weekly parent groups.95

2) Expand and taior pubic education eorts to settins outside heath care to

educate amiies about the sins o depression, its impact on chidren and where

to o or hep b both direct taretin pubic education campains to them as

we as to non-heath care proiders who requent come in contact with new

amiies in hih risk roups.

Providers who work with mothers who are depressed or in other stressul situations report that many

o these women do not seek health care or themselves, especially i they are no longer eligible or

health insurance. As a result, they may have only inrequent contact with health care proessionals

who are trained in identiying depression. According to public health workers, this is especially true

o many amilies utilizing the Women, Inants & Children (WIC) nutrition program. Financial

workers in welare oces also report high rates o depression in the amilies who they see. Even i

these mothers are eligible or Medical Assistance, their depression may be keeping them rom making

and keeping health care appointments. Other providers who come in contact with mothers at higher

risk o depression include sta in early childhood programs such as Head Start and Early Childhood

Special Education. Providing sta in non-health care settings with inormation alerting them to

the signs o depression and its impact on children, as well as with inormation they can provide to

women and their amilies about where to get help, provides another doorway through which to

reduce the impact o depression on young amilies.

STATE POlICy: Require a jointly prepared plan rom the Department o Health and the

Department o Human Services to reduce the disparities in postpartum inormation disseminationrefected in the PRAMS survey, including determining the desirability o increased outreach in WIC

oces. rack the impact through the PRAMS.


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3) Increase eorts b proessiona associations and proider roups to educate

their members reardin materna depression and its impact on chidren.

Te proessional associations or pediatrics, amily medicine, obstetrics and gynecology, or instance,

have established clear statements or their members regarding the importance o screening or

depression and its impact on children. Other proessional associations, such as nurses and social

workers, should examine their policy guidelines to ensure that the two-generation nature o

depression is addressed and communicated to their members. Tese groups could intensiy their

education and proessional technical assistance eorts.

4) Incorporate inormation about chid deeopment into hih schoo heath

curricuum.

Most high school students will eventually have children o their own, and many will work in jobs

where they care directly or children and their amilies. Introducing young people to even the

basic concepts o how children develop, what they can and cannot understand at certain ages, and

the importance o parent-child interactions may help improve amily relations and decrease child

maltreatment.

STATE POlICy: Require recommendations rom the Department o Education or incorporating

more inormation about child development and parental mental health in middle and/or high schoolcurriculum.

Eective Screening and Reerral to Services

Early identication o depression in parents and delays in childrens development is

key to minimizing and reversing its negative eects. Tis requires ully implemented

policies that result in comprehensive screening and appropriate reerral or urther

assessment and treatment o parents and/or their children, i indicated.

BACkgROUnD

SCREENINg AND REFERRAl IN HEAlTH CARE SETTINgS: Physician oces and clinics are

primary sites or the early detection o a variety o health conditions because nearly all new amilies

visit a health care provider in their childs rst year o lie. Mothers are screened or a number o

possible conditions as part o their prenatal and postnatal care, including gestational diabetes or lie-

threatening toxemia. Children are tested to be sure their growth (height and weight) is on track, and

their vision and hearing are unctioning as expected.

A major step orward in promoting a two-generation approach to maternal depression in state health

care programs was taken in 2010 by the Department o Human Services with its authorization o

reimbursement or maternal depression screening as part o inant well-baby check ups (up to age

one). Te results o each patients depression screening are kept in their le and not reported to the

state. Te table below shows the points in care that screening is recommended as good practice96 97


25/57


Best Practice Guidelines or Maternal Depression &

Early Childhood Screening Guidelines

It is dicult to determine, however, in either the private and public systems the degree to which

screenings, urther assessment and/or reerrals are actually occurring. Most o the inormation about

service provision in health care is collected through the billing process and depression screening

(except during a well-child check-up) is not billed or separately. I providers are not required to bill

separately or a service or the additional nancial reimbursement or ling a claim is not judged by

them to be worth the additional paperwork, there are no data to indicate whether or not a service

was perormed.

Te limited data that are available, as well as observations by health and related proessionals,

indicate that screening and reerrals are not occurring at the rate they should, based on the estimated

prevalence o depression and childhood developmental delays in the population. Given the high rate

o delays ound when children in this high-risk group are screened, these low screening rates should

be o concern to policymakers.

Te inormation below presents data on screening rates in Minnesotas public health programs or

childrens developmental and mental health progress.98 Te numbers are only an estimate because

(1) children can be screened more than once and

(2) the total number o children used to calculate the rate is based on the total number o children

enrolled in the states public health care programs, although ewer actually see a doctor each year, and

(3) some providers may be perorming the screenings but not submitting claims.

Nevertheless, despite the roughness o these estimates, it is clear that screening is still ar rom a

universal practice in health care providers oces.

Developmental and Mental Health Screening Rates

20072009-Minnesota Health Care Programs99

Type of screei we Primary Patiet

Maternal Depression Prenatal Visits Mother

Maternal Depression Postpartum Check-up Mother

Maternal Depression Well-Child Check-Up Inant

Inant Development (social-emotional,

mental health, cognitive,

speech/language, ne/gross motor)

Well-Child Check-Up Inant

Year number ofsocial-emotioal

screei

A a % ofEliible Cildre

Erolled

number ofDeelopmetal

screei

A a % ofEliible Cildre

Erolled

2007 598 .2% 56,600 45.2%

2008 2,868 .8% 62,765 38.9%

2009 6,456 1.7% 75,339 44.1%


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Many o the barriers to ully implementing eective screening and reerral practices relate to clinic

procedures and clinician knowledge and practice. Clinic procedures (e.g., ensuring parents ll out

orms and that the inormation is transmitted to clinicians or use during the oce visit) may not

exist to support eective screening and reerral. When potential problems are detected, insurance

reimbursement (MHCP and private) may not cover the costs associated with the ollow up care

coordination with other providers that may be necessary. In addition, many health care providers

have only a limited awareness o the adult and child mental health and early childhood services in

their communities, and their clinics are not set up to provide the necessary ollow-through to help

parents act on reerrals they receive. Providers report that the lack o eedback about results that otenoccurs ater a reerral is made is another barrier to eective practice.

Communication among providers is an important part o early identication o potential risks

or poor pregnancy outcomes. Some providers and health plans still use a protocol (Minnesota

Pregnancy Assessment Form), previously but no longer required by the states health care programs,

that noties local public health agency (or, in the past, health care plans) that an enrollee is pregnant

and considered at high risk or poor outcomes. Tis notice sets in motion reerrals or other services

to improve the chances or a healthy pregnancy and birth. Collocating mental health and primary

health care services also acilitates patients ollow-through on reerrals.

Important lessons or improving screening and reerral rates may emerge rom a pilot project currently

underway in the state. Te Department o Human Services has been involved in the AssuringBetter Child Health and Development (ABCD) project unded by the Commonwealth Fund and

administered by the National Association o State Health Programs since 2003. In the current phase

o the project, our clinics in dierent parts o the state (Anoka, Olmsted, Ramsey and St. Louis

counties) are changing their clinic processes and expanding their relationships with other providers

in their communities to improve their screening and reerrals rates. Wilder Research is evaluating

the eort. Results so ar have been promising and participants express particular appreciation or the

development o provider networks in their community. Te project will end in 2012.

SCREENINg & REFERRAl OUTSIDE OF HEAlTH CARE SETTINgS: Screenings or

maternal depression and early childhood development also occurs outside o health care provider

oces. A major public health eort administered through local public health departments is calledthe Follow Along Program. Parents use a sel-scoring tool to assess their childs development

rom inancy through age 3. I they choose, they can send the results to their county public health

department. I delays are detected, public health nurses contact the amily to oer additional

assistance, which may include oering to assess caregivers mental health.

Te Follow Along Program reports a high degree o satisaction by parents and has also successully

identied many children who could benet rom early intervention services. Currently, 12% o

children birth to age three have amilies participating in the Follow Along Program, with wide

ranges o participation by region. Some counties send inormation to all amilies. Others only

send inormation to amilies identied as high-risk. Although the cost is minimal ($42 per child

on average), continued local government aid cuts threaten the viability o the program in some

counties.100

Sarah ailed the 8-month ASQ [developmental screening] and James ailed

the 18-month ASQ in the Communication domain. The PHN [Public Health

Nurse] made a home visit and discovered a severely depressed mother

who was pregnant with her 3rd child. Mom stated that she did not enjoy

being a mom anymore...The PHN called the physician who had no idea

that this mother was severely depressed. Mom saw the physician and is

under treatment. These childrens [poor] scores are probably due to moms

depression. Follow Along Program Case Story101


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Other screening occurs in programs primarily serving low income amilies only. Family home visitors

and Early Head Start programs, or example, screen or maternal depression and early childhood

delays. Child protection and early childhood special education also screen children or developmenta

and other delays. All o these settings oer the opportunity to utilize a two-generation approach to

screening and reerral since they see both mother and child. However, the little data that are available

indicate reerrals or additional assessment or treatment are lower than expected rom these sources as

well as rom health care providers, and reerrals are also oten not timely.

WIC (Women, Inants & Children) clinics see many young amilies (50% o all births in the state)but are not unded to conduct screenings or otherwise provide inormation on maternal depression

or early childhood development to amilies.

Churches serving primarily Arican-American amilies on the North Side o

Minneapolis are helping amilies track their own childrens development by

training lay-people in early childhood screening.102

Some o the children most in need o mental health services are those that have been removed rom

their homes due to trauma, neglect, abuse or witnessing violence. Yet, only a little over hal (55%) o

these children received the required mental health screening in 2009.103

OPTIOns TO IMPROvE sCREEnIng AnD REFERRAL RATEs FOR MATERnAL DEPREssIOnAnD EARLY ChILDhOOD DEvELOPMEnT

1) Support proiders in their understandin o current poicies and procedures

throuh increased technica assistance and uidance.

Although training and inormational materials are available through the Departments o Human

Services, Health and Education, the need or more technical assistance has been identied by health

care providers and plans. Some providers-especially pediatricians-express discomort discussing

possible depressive symptoms with their patients mothers. Others are reluctant to discuss mental

health related issues with patients in general, given concerns about stigma or labeling associated

with cognitive, behavioral or emotional delays in children. Some providers are concerned aboutlegal liability issues associated with screening. Making providers more aware o some o the resources

provided by their colleagues would be helpul. Awareness o adult and childrens mental health

resources to which primary care providers can reer patients is also critical.

Hennepin County Medical Centers Womens Mental Health Program

provides support or other health care providers serving women with

reproductive-related psychiatric conditions. Currently provided ree o

charge through grants rom Jennys Light and Hennepin Health Foundation,

its provider warm line oers web-based, phone-based and on site support

to help clinics and health care providers set up screening, assessment and

treatment programs.104

STATE POlICy: Provide the Department o Human Services with additional resources and/or the

fexibility to contract with a non-prot organization(s) to increase screening and reerral rates in

primary health care settings, including culturally competent eective practice and administrative

issues such as billing and record-keeping.

STATE POlICy: rack and report on the impact o policies on maternal depression rates through

the PRAMS and child development through available measures, including the School Readiness

report card currently under development through the Department o Education.


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2) Ensure sucient resources are aaiabe or proiders to coordinate care or

mothers and chidren who need additiona assessment and reerra.

Families with caregivers experiencing serious mental health disorders may especially need additional

assistance to ollow through on reerrals.

In Douglas County, sta rom health care clinics, a local health plan, the

school district and county mental health services collaborated when they

saw their costs or deep end care or children in psychiatric and residential

settings increasing rapidly. With a small amount o seed money rom the

Robert Wood Johnson Foundation and the Department o Health, and some

technical assistance rom the University o Minnesota, they determined how

best to t screening or childrens social-emotional development into the

primary care settings. The health plan (Prime West) pays or a health care

coordinator at the Alexandria Clinic. Clinic procedures have been modied

to support screening and reerrals, and a network o providers has been

established and strengthened. Since the eort began, the use o more costly

and deep end services has been reduced and providers believe children

and their amilies are being better served overall.105

3) Assure heath care proiders that the patients the hae screened andidentied as needin additiona assessment and/or treatment can receie that

care.

Currently, Medical Assistance coverage or new mothers postpartum care ends at six weeks. Tis was

identied as a barrier by many providers who expressed concern about the implications o identiying

a medical condition such as depression that could not be treated due to lack o insurance coverage.

Tis recommendation is also included in the next section.

STATE POlICy: Extend MA postpartum care or two years ater a childs birth.

4) Address eectie screenin and reerra or materna depression and ear

chidhood in the practice and inormation sstems chanes accompanin edera

heath care reorm.

Tis includes making sure models or health care homes and electronic record keeping practices

include provisions that strengthen screening and reerrals or mental health disorders. For instance,

cues to prompt providers to screen or maternal depression could be embedded in the electronic

medical records o inants.

STATE POlICy: Provide and enhance nancial incentives to increase screening rates until they

reach acceptable levels. Require the use o standardized screening tools or reimbursement and

ensure the record-keeping requirements established through health care reorm support systematic

screening.106

Minnesota successully increased its public health care programs child &

teen check-up rates with scal incentives and its lead level screenings ater

it began withholding payments or providers not meeting state standards.107

5) Hep amiies naiate the menta heath and heath care sstem.

Figuring out where to go or help and or which programs they may be eligible, as well as correctly

lling out the required paperwork, is a major task or most people utilizing the current health care

system. Tis is truer or amilies i the primary caregiver is depressed, with ew resources and or


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whom English is not the primary language. Community Health Workers represent a relatively new

way to help these amilies.108 Tese workers come rom the communities in which they serve and

help to orm a bridge between their communities and systems o care. Already working with mental

health providers in some areas o the state, this model has the potential to assist amilies whose

caregiver needs additional assistance nding appropriate providers and ollowing through on reerrals

and treatment. Te Follow Along Program, administered by the Department o Health and operated

by local health departments is another doorway into the health care system or some amilies.

STATE POlICy:Continue to support Community Health Workers and provide additional trainingand technical assistance to increase their use in mental health settings.

STATE POlICy: Ensure stable unding or the Follow Along Program by providing state unds.

Provide scal incentives to encourage every county to reach out to all amilies.

6) Interate materna depression into the enera depression screenin protoco

supported b man priate insurers and cinics in the state.

Since 2008, many providers and health plans have been participating in an eort to address

depression in their adult patient population in general. DIAMOND (Depression Improvement

Across Minnesota, Oering New Direction), initiated by the Institute or Clinical Systems

Improvement (ICSI), has developed protocol, redesigned payments and educated providers oneective treatment or depression.109 Currently, the system does not specically address maternal

depression.

According to health plan representatives, providers generally nd it easier to use the same protocols

or all o their patients. Tereore adoption o best practices in public mental health program policies

is likely to be replicated in practices aecting patients covered by private insurance as well.

New Jersey requires health care providers to screen all women who have recently given birth or

depression. In addition, providers are required to ask all pregnant women about their history o

depression. Te law was accompanied by a public awareness campaign Speak Up When Youre

Down.110

7) Across a settins, determine the extent to which appropriate screenins and

reerras or menta heath serices are occurrin in heath care and non-heath

care settins, and impement measures to improe screenin and reerra rates to

their expected ees.

Current data sources provide little insight regarding the extent to which reerrals and made and

ollowed up on, or the reasons why reerrals are not occurring when they should. Hypotheses include

a lack o awareness on the part o providers regarding community resources, or reluctance in some

proessions to reer to the mental health system due to concerns about stigmatizing children or their

amilies, and lack o resources to ollow-through on reerrals. Given the importance o this step to

mothers and children needing mental health services, a cross-disciplinary in-depth look at the issuesmay be necessary to begin to determine both the actual scope o the problem and possible solutions.

STATE POlICy: Convene task orces to study (1) the easibility and desirability o expanding and/

or ormalizing screening in non-health care settings, (2) the desirability o mandatory screening or

depression, and (3) issues in reerrals or adult and child mental health services including a review o

a sample o cases tracking the path rom screening to reerral, services and outcomes by diagnosis and

provider type (e.g., public health agencies, pediatricians, etc) and by county, race and ethnicity to

detect practice disparities.


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Family-Focused Two-Generation Programs

Mothers needing mental health services should receive culturally appropriate treat-

ment that both addresses their depression and helps them with parenting. Teir

children need stimulating environments and experiences that mitigate the negative

eects o their primary caregivers depression and help promote positive parent-child

attachment.

BACkgROUnD

Little is known about the parenting status o most o the adults receiving mental health services in

the state. Tis inormation is rarely collected at intake or clients in either public or private mental

health systems, and is oten not part o treatment plans, or considered when discharge plans are

being made or parents who have been hospitalized.111 Minnesotas current adult mental health

system also does not have provisions specically intended to help adults parenting their children.

Proessionals in the eld observe that reerrals to childrens mental health services rom adult mental

health and public health services are lower than expected, indicating that many children who are

vulnerable to being aected by the parents mental illness are not being fagged by the systemsserving their parents.

Minnesota does have several providers who can provide two-generation, amily-based care. In

addition, an eort is currently underway to expand the use o a diagnostic tool (DC 0-3) that

ocuses on the parent-child relationship. Medical Assistance reimbursement is available or services

to children and amilies needing therapy identied through their childs social or emotional delays.

Still, most children who are at risk or, or already experiencing, delays due to their parents untreated

depression do not receive services. Reasons include their mothers lack o health care coverage,

undetected social-emotional or other delays, lack o mental health p

Documents

Maternal Depression Report