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ECIN Briefing

Building resilient kids through healthy adults

ECIN Briefing

Mr. Lane, Dr. Hodgkinson, Dr. Biel, and Dr. Beers provided a briefing at the Washington, D.C., City Council in July about the Early Childhood Innovation Network, which takes evidence-based national models for early childhood mental health interventions and adds components designed to address Washington, D.C.’s unique needs.

Exposures to adverse childhood experiences are the single biggest predictor of outcomes for physical health, mental health, social functioning and academic achievement in children and into adulthood. There is evidence that negative experiences – such as poverty, housing insecurity, having a parent with untreated mental illness or actively engaged in substance abuse – have biological impacts on a child’s brain size and function.

Conversely, during the critical first few years of life, safe, stable and nurturing relationships from adult caregivers build healthy brains, even in the midst of adversity. Additionally, the ability of a child’s brain to absorb experience and to change means that early intervention to reduce exposure to or impact of these negative events can be particularly effective for young children. In a briefing for the Washington, D.C., City Council, leaders from the Early Childhood Innovation Network (ECIN) shared these facts and outlined how ECIN’s local collaborative of health, education and social service providers promotes resilient families and children through interventions designed to work best for each family.

“We are taking evidence-based practices from other places, and then personalizing them to our communities in D.C.,” says Lee Beers, M.D., co-director of the ECIN and the medical director for Municipal and Regional Affairs within the Child Health Advocacy Institute at Children’s National Health System. “We spent a lot of time seeking input and advice from primary care doctors, social services providers and community leaders, to make sure that we bring programs to clinics like the Children’s Health Center at Anacostia that are useful, sustainable and measurable for the children and families who live there.”

The network’s other co-director, Matthew G. Biel, M.D., chief of the Division of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital continues, “We know that the best way to help these kids is by addressing challenges across generations – we can’t reach children without first helping the adults. In addition to evaluating for risk factors, we also need to screen for protective factors – how families can best buffer these young children from the toxic effects of adverse childhood experiences. Then, in a non-confrontational setting such as a routine primary care visit, we can provide them with additional tools to enhance those protective factors.”

A working example: HealthySteps D.C.

Drs. Beers and Biel cited the implementation of the HealthySteps program, an evidence-based intervention with a national network of over 100 pediatric and family practice sites across 15 states, locally in D.C. as one example of ECIN’s approach. The program, now underway at the Children’s Health Center at Anacostia and recently launched at the Children’s Health Center at THEARC, embeds specially trained HealthySteps specialists into the primary care team to provide parents and professionals with skills and tools that nurture healthy development in young children.

Nationwide, HealthySteps has been shown to have a significant impact on children, families and practices at relatively low cost, providing services within the primary care setting such as:

  • Early identification and access to effective interventions for development delays
  • Coaching on age-appropriate parent-child interactions and child social-emotional development
  • Support for parental depression, domestic violence, substance abuse, food, housing and other social determinants
  • Creating better integration between pediatric primary care and early childhood systems

ECIN’s D.C.-based version takes this successful national model and adds additional D.C. needs-based specific activities:

  • Each family is assigned a Family Champion who identifies and addresses specific resource needs, including mental health services, parent training, or support groups and basic needs such as insurance, housing or employment
  • HealthySteps specialists offer brief interventions within the primary care setting to address pressing needs such as maternal depression, grief and loss and child behavior management
  • HealthySteps specialists deliver specialized training to providers on child behavioral and developmental health

“Even in the short time since we implemented HealthySteps, we’re seeing significant impact around care coordination and case management for the families at our Children’s Health Center at Anacostia,” says Stacy Hodgkinson, Ph.D., a licensed clinical psychologist at Children’s National who serves as a HealthySteps specialist at the Children’s Health Center at Anacostia.

HealthySteps D.C. is the first of several initiatives under development by the Early Childhood Innovation Network. The group is also working together with additional community partners such as Educare, Martha’s Table, LIFT, and MedStar Washington Hospital Center to explore, implement and evaluate the effectiveness of programs in areas such as building social-emotional skills in young children, financial literacy and mental health support for mothers-to-be.

Community connections and coordination

“So many children with needs do not get connected to services, and the Early Childhood Innovation Network addresses this challenge. Even better, there has been a genuineness from ECIN to engaging community and earning buy-in for programs from the very beginning. They’ve made community leaders and parents an integral part of the network’s program design and implementation,” adds Ambrose Lane, Jr., chair and founder of the Health Alliance Network and chairman at the D.C. Department of Health Chronic Disease Citywide Collaborative.

Stacy Hodgkinson, Ph.D. Psychologist, Generations Program Director of Mental Health and Research and Study Lead Author

Improving mental health service access

Woman sitting on chair

Psychologist Stacy Hodgkinson, Ph.D., has been implementing a new strategy — integrating mental health services with primary care — to increase patients’ access to mental health care.

Children are disproportionately affected by poverty in the United States: Although they make up less than one-quarter of the entire population, about one-third of people living in poverty are kids. Lack of economic resources in childhood can have lifelong effects, including increasing the chances of experiencing a variety of mental health issues.

What’s more, although kids living in low socioeconomic settings are more likely to need mental health care, studies show that they are less likely to receive it, says Children’s National Health System Psychologist Stacy Hodgkinson, Ph.D. Estimates indicate that fewer than 15 percent of children living in poverty who need mental health care receive any services, and even fewer get comprehensive treatment.

The reasons for this disparity are multifold, Hodgkinson explains. One reason is simply insufficient numbers of trained mental health care providers to meet demand, particularly in low-income communities. Another is an inability to access available services —parents in low-paying jobs may not be able to take time off to take their children to appointments or even afford bus fare to reach a clinic. Others are afraid of the stigma that might surround being treated for a mental health issue. In her role as the director of mental health and research for the Generations Program, a support service for teen parents and their children, Hodgkinson says she has seen each of these scenarios in play.

However, she adds, over the past several years, she and Children’s National colleagues have been implementing a new strategy to increase mental health care access: Integrating these services with primary care.

“Often times, a family is with a primary care provider throughout a child’s life into adulthood. It’s a natural, familiar setting where people feel comfortable,” Hodgkinson says. “That makes a primary care provider’s office really fertile ground for integrating mental health services.”

Hodgkinson and coauthors point out in a review paper published in the January 2017 issue of Pediatrics that most children see their primary care provider for annual well visits as well as when they are sick — regardless of household income. Those visits provide ample opportunities for parents to bring up other concerns or for providers to implement screening that could lead to a mental health diagnosis. From there, she explains, that provider can offer mental health support and facilitate a connection with a mental health provider who works in the same office or who works in partnership with the primary care office.

In the review, she and colleagues suggest several strategies for making this idea become a reality. The first step, they agree, is education. Beginning with their fundamental training, primary care doctors and mental health providers need to see their roles as conjoined.

“We really need to change the way people think about primary care,” Hodgkinson says. “Disciplines don’t have to be siloed, where primary care providers do their thing here and mental health providers do their thing there. We should be thinking about how we can bring everyone together under one tent.”

Many psychology training programs have primary care integration rotations, she adds, and an increasing number of health systems like Children’s National now have mental health providers working in the same offices as primary care providers.

But not every clinic has the resources to group providers together under a single roof. Even for those offices, Hodgkinson says, primary care doctors need to develop a workflow that streamlines patients who need mental health services to health care professionals who provide it. In some cases, that might mean making the referral call on patients’ behalf to ensure they get through, walking families through the specific information they will need if they make the call on their own and following up to troubleshoot any problems with access.

“We want to close as many gaps as we can to keep families from falling through the cracks,” she says.

Developing an infrastructure that supports this model also can’t be ignored, Hodgkinson points out. Primary care offices might need to determine how to allocate space to mental health providers, hire dedicated workers to improve access and develop new strategies for billing.

None of this will be easy, she adds, but it will be worth it to make sure that more patients receive needed services.

“Even though we have integrated mental health and primary care at Children’s National, it very much remains a work in progress, and we’re continuing to fine-tune this machine to make it work better,” she says. “But if a patient comes to even one appointment that they might not have made it to in the past, that’s an accomplishment.”