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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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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
National Research Council and Institute o Medicine
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
National Research Council and Institute o Medicine
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
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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