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PICU room

How to help bereaved families

PICU room

To help clinicians provide better care to families after children die, Tessie W. October, M.D., MPH, and colleagues recently published an article on this topic in a special supplement to Pediatric Critical Care Medicine on death and dying.

Death and dying are always difficult topics to discuss at hospitals. They’re especially hard conversations when they occur within pediatric intensive care units (PICUs), says Tessie W. October, M.D., MPH, a critical care specialist at Children’s National.

“It’s almost easier to pretend that children don’t die in the ICU. But they do,” Dr. October says.

Tragically, some children do die in ICUs. However, even when pediatric patients die, Dr. October adds, the pediatric care team’s relationship with the bereaved family continues. Knowing how to help vulnerable families during these trying times and ensuring they have needed resources can be critical to lessening the health and social consequences of grief. To help clinicians provide better care to families after children die, Dr. October and colleagues recently published an article on this topic in a special supplement to Pediatric Critical Care Medicine on death and dying.

The multi-institutional research team performed a narrative literature review for this budding field. They pored through more than 75 papers to better understand the health outcomes of parents whose child died within a PICU and the different ways that hospitals help families cope with these tragedies.

The researchers found a range of detrimental health outcomes, from a significantly increased risk of parental death in the aftermath of a child’s death to higher rates of myocardial infarction, cancer and multiple sclerosis. Bereaved parents used more health care resources themselves, took more sick days and had more sleep problems than parents who weren’t bereaved.

Likewise, parents whose child died were at a high risk of experiencing mental health conditions including complicated grief, anxiety, depression and posttraumatic stress disorder. Divorce was eight times higher among bereaved parents compared with the general population, and financial crises were common after voluntary or involuntary unemployment.

Knowing which risks parents could face can help the care team respond better if a child dies, Dr. October explains. Their review highlighted simple ways to support families in the immediate aftermath of a child’s death and beyond, such as:

  • Giving parents the opportunity to spend time alone with the child’s body
  • Allowing friends, family and others to visit at the parents’ discretion and
  • Providing easy access to professional support, such as chaplains, social workers and grief coordinators.

Even simple acts such as closing doors and blinds to provide privacy can be helpful, Dr. October says.

An ongoing relationship with health care providers is also important for helping parents grieve, she adds. Children’s National is among hospitals across the country to set up meetings for parents and other family members within weeks of a child’s death. This gives parents a chance to ask questions about what happened in the confusing blur of the PICU and to gather resources for themselves and surviving siblings. Children’s National also provides ongoing support through periodic calls, sending sympathy cards, attending funeral services and in a special annual memorial during which surviving family members release butterflies.

“Our role doesn’t end when a child dies,” Dr. October says. “To help parents through bereavement, we need to maintain that strong connection.”

Another way to help bereaved families is to make sure they have adequate information, she adds, particularly about the confusing subject of brain death. In a different study recently published in Chest Journal, Dr. October and Children’s colleagues sought to understand which information the public typically accesses about this topic.

The team searched Google and YouTube using “brain dead” and “brain death” as search terms. They evaluated the top 10 results on both sites, assessing the accuracy of information using 2010 guidelines released by the American Academy of Neurology. They also assessed the reading level of websites and evaluated comments about the YouTube videos for content accuracy and tone.

They found that there was inaccurate information on four of the 10 websites, six of the 10 videos and within 80 percent of the YouTube comments. Most of these inaccuracies dealt with using terms like brain death, coma and persistent vegetative state interchangeably. “These conditions are very different and affect how we treat patients,” Dr. October says.

The average reading level of the websites was 12th grade, far too sophisticated for much of the public to comprehend, she adds. And the majority of comments on the YouTube videos were negative, often disparaging clinicians and deriding organ donation.

“It’s really important for providers to recognize that this is an emotionally laden topic, and a lot of times, families come to us with information that’s not always true,” she says. “That’s why it’s especially important for the field to respond with empathy and care.”

In addition to Dr. October, co-authors of the Pediatric Critical Care Medicine study include Karen Dryden-Palmer, R.N., MSN, Ph.D., The Hospital for Sick Children; Beverley Copnell, Ph.D., BAppSc, R.N., Monash University; and Senior Author Kathleen L. Meert, M.D., FCCM, Children’s Hospital of Michigan. Dr. October’s co-authors for the Chest Journal article include Lead Author, Amy H. Jones, M.D., and co-author Zoelle B. Dizon, BA, both of Children’s National.

CASD Posters

Bridging gaps in autism care through technology

CASD Posters

CASD Faculty Member and Clinical Psychologist, Dr. Allison Ratto (top left); Postdoctoral Fellow, Dr. Marissa Miller, (top right); and Research Assistants, Eleonora Sadikova (bottom left) and Laura Saldana (bottom right) presented posters at ABCT.

Technology’s potential to improve care delivery and reduce human suffering were the key focus of discussion at the recent Annual Convention of the Association for Behavioral and Cognitive Therapies (ABCT), held in Washington, D.C.

Within ABCT’s Autism Spectrum and Developmental Disabilities Special Interest Group (ASDD SIG), presentations showcased tools that leverage technology to better meet the needs of both autistic people and the clinicians who care for them. Researchers from the Center for Autism Spectrum Disorders (CASD) at Children’s National took center stage at the ASD focused group to share information about novel developments underway that harness technology for children and families.

Lauren Kenworthy, Ph.D., director of CASD, served as the keynote speaker for the ASDD SIG Meeting. She also chaired a panel, “Leveraging Technology to Improve Autism Acceptance and Treatment” and presented, ” Online Parent Training Modules to Improve Executive Function in Autistic Children” about the e-Unstuck and On Target Parent Training Study, which adapts CASD’s successful classroom-based Unstuck and On Target toolkit for children ages 5 to 10 to an online platform so more families can benefit from the program’s skills and strategies.

Dr. Kenworthy was honored with the 2018 Transformative Contribution Award from the ABCT Autism Spectrum and Developmental Disabilities Special Interest Group for her lifetime of contributions to better understanding and better interventions for young people with ASD.

“It was a special honor to receive this recognition from ABCT this year, when the annual meeting is here in our home city,” says Dr. Kenworthy. “The Center for Autism Spectrum Disorders is focused on developing technology solutions that deliver therapies to everyone who needs them, no matter where they live, and technology is one powerful and promising way we can bridge care gaps both in the Washington, D.C. region and really, around the world.”

CASD Talks

Dr. Lauren Kenworthy presenting during the panel she chaired (top); presenting to the ASDD SIG (bottom left); and receiving the ASDD SIG Transformative Award from ASDD SIG Awards Committee Chair, Dr. Tyler Hassenfeldt (bottom right).

In addition to Dr. Kenworthy, several other CASD researchers presented research during panels and poster presentations, including:

  • Panel Presentation: Efficacy of a Parent-Mediated Sexual Education Curriculum for Youth With ASD”– Cara Pugliese, Ph.D.
  • Poster presentations:
    • “Evidence of Enhanced Social Skills in Young Dual-Language Learners on the Autism Spectrum”- Allison Ratto, Ph.D. (first author)
    • “Exploring Contributors to Parents’ Ideal and Realistic Goals for Involvement in School Training”-Marissa Miller, Ph.D. (first author)
    • “Examining Caregiver Well-Being and Service Use between Latino and Non-Latino Caregivers”-Laura Saldana (first author)
    • “Pre-Pubertal Signs of Future Gender Dysphoria in Youth with ASD”-Eleonora Sadikova (first author)

The Association for Behavioral and Cognitive Therapies Annual Convention has been held for more than half a century. The gathering includes 3,500-plus mental health professionals and students who specialize in cognitive and behavioral therapies.

child measuring belly with tape measure

Children’s obesity research team presents compelling new findings

child measuring belly with tape measure

Faculty from Children’s National Health System’s Department of Psychology & Behavioral Health set out to learn if any demographic, psychiatric, or cognitive factors play a role in determining if an adolescent should be eligible for bariatric surgery, and what their weight loss outcomes might be. Presenting at the Society for Pediatric Psychology Annual Conference earlier this month, a group of researchers, fellows and clinicians, including surgeons from Children’s National showcased their findings. One of the posters developed by Meredith Rose, LGSW, ML, who works as an interventionist on a Children’s National clinical research team, received special recognition in the Obesity Special Interest Group category.

One presentation reported on a total of 222 pediatric patients with severe obesity, which is defined as 120 percent of the 95th percentile for Body Mass Index. Mean age of the participants was 16 years of age, 71 percent were female and 80 percent where Hispanic or non-White. As part of their preparation for surgery, all patients were required to complete a pre-bariatric surgery psychological evaluation, including a clinical interview and Schedule for Affective Disorders and Schizophrenia (KSADS-PL) screening. The studies by the Children’s teams were based on a medical record review of the pre-screening information. Adolescents being evaluated for surgery had high rates of mental health diagnoses, particularly anxiety and depression, but also included Attention Deficit Hyperactivity Disorder, eating disorders, and intellectual disability.

Another Children’s presentation at the conference looked at weight loss outcomes for adolescents based on IQ and intellectual disability. Overall, neither Full Scale IQ from the Wechsler Abbreviated Intelligence Scale – 2nd edition, nor the presence of an intellectual disability predicted weight loss following surgery.

“The sum of our research found that kids do really well with surgery,” said Eleanor Mackey, PhD, assistant professor of psychology and behavioral health. “Adolescents, regardless of the presence of intellectual disability areas are likely to lose a significant amount of weight following surgery,” added Dr. Mackey.

“This is a particularly important fact to note because many programs and insurers restrict weight loss surgery to ‘perfect’ candidates, while these data points demonstrate that our institution does not offer or deny surgery on the basis of any cognitive characteristics,” says Evan P. Nadler, M.D., associate professor of surgery and pediatrics. “Without giving these kids a chance with surgery, we know they face a lifetime of obesity, as no other intervention has shown to work long-term in this patient population. Our research should empower psychologists and physicians to feel more confident recommending bariatric surgery for children who have exhausted all other weight loss options.”

The research team concluded that examining how individual factors, such as intellectual disability, psychiatric diagnoses, and demographic factors are associated with the surgery process is essential to ensuring adequate and empirically supported guidelines for referral for, and provision of bariatric surgery in adolescents. Next steps by the team will include looking into additional indicators of health improvement, like glucose tolerance, quality of life, or other lab values, to continue evaluating the benefits of surgery for this population.

Maureen Monaghan

Using text messages and telemedicine to improve diabetes self-management

Maureen Monaghan

Maureen Monaghan, Ph.D., C.D.E., clinical psychologist and certified diabetes educator in the Childhood and Adolescent Diabetes Program at Children’s National Health System, awarded nearly $1.6 million grant from American Diabetes Association.

Adolescents and young adults ages 17-22 with Type 1 diabetes are at high risk for negative health outcomes. If fact, some studies show that less than 20 percent of patients in this population meet targets for glycemic control, and visits to the Emergency Department for acute complications like diabetic ketoacidosis peak around the same age.

The American Diabetes Association (ADA) awarded Maureen Monaghan, Ph.D., C.D.E., clinical psychologist and certified diabetes educator in the Childhood and Adolescent Diabetes Program at Children’s National Health System, nearly $1.6 million to evaluate an innovative behavioral intervention to improve patient-provider communication, teach and help patients maintain self-care and self-advocacy skills and ultimately prepare young adults for transition into adult diabetes care, limiting the negative adverse outcomes that are commonly seen in adulthood.

Dr. Monaghan is the first psychologist funded through the ADA’s Pathway to Stop Diabetes program, which awards six annual research grants designed to spur breakthroughs in fundamental diabetes science, technology, diabetes care and potential cures. Dr. Monaghan received the Accelerator Award, given to diabetes researchers early in their careers, which will assist her in leading a behavioral science project titled, “Improving Health Communication During the Transition from Pediatric to Adult Diabetes Care.”

“Behavior is such a key component in diabetes care, and it’s wonderful that the American Diabetes Association is invested in promoting healthy behaviors,” says Dr. Monaghan. “I’m excited to address psychosocial complications of diabetes and take a closer look at how supporting positive health behavior during adolescence and young adulthood can lead to a reduction in medical complications down the road.”

During the five year study, Dr. Monaghan will recruit patients ages 17-22 and follow their care at Children’s National through their first visit with an adult endocrinologist. Her team will assess participants’ ability to communicate with providers, including their willingness to disclose diabetes-related concerns, share potentially risky behaviors like drinking alcohol and take proactive steps to monitor and regularly review glucose data.

“The period of transition from pediatric to adult diabetes care represents a particularly risky time. Patients are going through major life changes, such as starting new jobs, attending college, moving out of their parents’ homes and ultimately managing care more independently,” says Dr. Monaghan. “Behavioral intervention can be effective at any age, but we are hopeful that we can substantially help youth during this time of transition when they are losing many of their safety nets.”

Study leaders will help participants download glucose device management tools onto their smartphones and explain how to upload information from patients’ diabetes devices into the system. Participants will then learn how to review the data and quickly spot issues for intervention or follow-up with their health care provider.

Patients also will participate in behavioral telemedicine visits from the convenience of their own homes, and receive text messages giving them reminders about self-care and educational information, such as “Going out with your friends tonight? Make sure you check your glucose level before you drive.”

At the study’s conclusion, Dr. Monaghan anticipates seeing improvements in psychosocial indicators, mood and transition readiness, as well as improved diabetes self-management and engagement in adult medicine.

Lee Beers

Mental health screenings increase in practices with hands-on support

Lee Beers

A new study suggests many more pediatricians would make mental health screenings an integral part of a child’s annual checkup if they received training and support through a proven and powerful method used to improve health care processes and outcomes.

Results of the multidisciplinary study led by Children’s National Health System and published in Pediatrics, showed screening rates improved from one percent to 74 percent during the 15-month study. A total of 10 pediatric practices and 107 individual providers in the Washington, D.C., area voluntarily participated in the study.

“This study is an important first step towards early identification of children with mental health concerns,” says Lee S. Beers, M.D., the study’s lead author. “If you identify and treat children with mental health concerns earlier, you’re going to see better outcomes.”

In this country, approximately 13 percent of youth live with a serious mental illness, but only about 20 percent of them get the help they need, according to the D.C. Collaborative for Mental Health in Pediatric Primary Care. 

While many pediatricians agree that early mental health screenings are important, the researchers found that few providers were actually conducting them. In the past, primary care providers have cited a shortage of pediatric mental health providers, a lack of time, insufficient resources and lower reimbursements.

To address the lack of mental health screenings, researchers decided to test whether the Quality Improvement (QI) Learning Collaborative model, which was pioneered in the mid-1990s to scale and improve health care services, would help study participants integrate screenings into their practices.

The QI Learning Collaborative model takes a more hands-on approach than the typical “once and done” study, says Beers. Specifically, the participating primary care providers received periodic check-ins, ongoing support, monitoring and technical assistance. “We use rapid cycles of evaluation to see what’s working and what’s not working, and we keep going,” Beers says.

Dr. Beers is optimistic about how well the practices performed, adding the caveat that more information is needed about the burden it could place on already bustling pediatric practices. In addition, she says, “future research will be needed to determine whether identifying mental health issues also leads to improved access to care and outcomes for pediatric patients.”

Dr. Beers serves as medical director for Municipal and Regional Affairs at the Child Health Advocacy Institute (CHAI), part of Children’s National. CHAI is a founding member of the D.C. Healthy Communities Collaborative (DCHCC), which partnered on the study with the Georgetown University Medical Center and the Georgetown University Center for Child and Human Development.

Olanrewaju-Falusi

Improving health care for immigrant children

Olanrewaju-Falusi

Immigrant children may face multiple and complex challenges that underlie seemingly routine health concerns that bring them to clinic, says Olanrewaju Falusi, M.D., F.A.A.P.

Over the next 40 years, children of immigrant families will grow to represent one-third of residents of the United States. To help more pediatricians address the interplay between immigration and child health, a Children’s National Health System clinician helped to compile a set of case studies, resources and recommendations.

Olanrewaju Falusi, M.D., F.A.A.P., and a colleague explained these issues during their joint presentation, “Advancing health care quality for immigrant children,” during the 2017 American Academy of Pediatrics (AAP) national conference. The aim of the presentation and of their work is to help pediatricians understand the impact of immigration-related issues and unresolved immigration status on children’s mental health and well-being.

“As pediatricians, we are tasked with caring for the whole child. And, for immigrant children, there may be multiple and complex challenges that underlie seemingly routine health concerns that bring them to clinic,” says Dr. Falusi, associate medical director of municipal and regional affairs at the Child Health Advocacy Institute at Children’s National. “By more fully understanding immigrant children’s unique needs, we can help bolster their resiliency.”

Though refugees may be resettled anywhere, in fiscal year 2016 almost 7,400 unaccompanied children were released to sponsors in California, the highest of the states. In five states (California, Illinois, Massachusetts, New York, Washington state and the District of Columbia) immigration status has no bearing on a child accessing public health. Undocumented immigrants, however, are not eligible for subsidies that lower the price of health insurance. Nor can they access such federal entitlements as SNAP (formerly known as Food Stamps). Even something as basic as having a ride to a doctor’s appointment can be complicated since only one dozen states offer access to driver’s licenses regardless of immigration status.

Using the case of a child named “Pedro,” who feared deportation, Dr. Falusi and a colleague explained how immigration status impacts access to clinical care, discussed DACA, his parent’s undocumented status and explored how clinicians could support Pedro and his family.

In another scenario, Esperanza comes to clinic with her 3- and 6-year-old sons, who are afraid to leave her side. Since the family fled Honduras and settled in the United States, Esperanza worries about her older daughter’s behavioral problems in school.

“These are challenging mental health concerns to unravel because some families may be reluctant to reopen past traumas,” Dr. Falusi says. “During their flight from their home country, children can be victims of or witnesses to violence, including rape. They may have seen another person drown during a water crossing or die in arid deserts.”

Clinicians can begin such conversations simply by trying to understand why Esperanza and her children came to the United States in order to consider the range of options for appropriate clinical care, as well as possible legal services. Bridging from that more neutral starting point, the health care team could delve into her family’s experiences in Honduras. If Esperanza fears returning to Honduras, asylum may be an option if her fears are well-founded and the persecution is due to race, religion, nationality, political opinion or membership in a particular social group, Dr. Falusi says.  Additional options may include T visas and U visas for victims of certain crimes.

“We are all aware how little time there is during the clinical encounter to have such detailed conversations. Ideally, the clinician would serve as a trusted intermediary, helping the family connect with community resources in order to best address the unique social needs of immigrant children,” Dr. Falusi says.

Teens Meditating

Namaste: how mindfulness aids cardiac patients

Teens Meditating

Mindfulness techniques – including yoga, meditation, group support, and other approaches to dealing with stressors – help teens with heart conditions reduce stress levels and better cope with health concerns.

An estimated 30 to 50 percent of teens with congenital heart conditions will experience anxiety and/or depression disorders, but researchers at Children’s National Health System have found that mindfulness techniques such as yoga, meditation and peer support can reduce stress that is often associated with these debilitating conditions.

Published in the journal Pediatric Cardiology, the first-of-its-kind, randomized, two-group study documented the effectiveness of Mindfulness-Based Stress Reduction (MBSR) and online video support groups in lowering illness-related stress for youth with heart conditions. Beyond stress reduction, the study also found that greater use of coping skills predicted lower levels of depression for participants following the interventions. Additionally, patients with higher levels of anxiety and depression pre-intervention recorded the biggest improvements post-study.

“Being a teenager is hard enough, but being the only person you know with a potentially life-threating heart condition can be devastating,” says Vicki Freedenberg, RN, Ph.D., electrophysiology nurse within the Children’s National Heart Institute and the principal investigator for the study. “These results indicate that teaching patients coping skills and connecting them with their peers can not only reduce their stress levels now, but these tools could also dramatically improve their responses to stressors for the rest of their lives.”

MBSR employs psycho-educational tools, including yoga, meditation, group support and other mindful approaches to dealing with stressors – which, for teens with heart conditions, could translate to better coping techniques when anxiety and heart palpitations strike.

Participants were randomly assigned to the MBSR group or the video online support group for the six-week study. The study included 46 adolescents, ages 12 to 18, with congenital heart disease, cardiac arrhythmias, cardiac devices or postural orthostatic tachycardia syndrome. Before and after the study period, patients self-reported illness-related stress and coping using the Responses to Stress Questionnaire, as well as anxiety and depression levels using the Hospital Anxiety and Depression Scale.

Participants in the MBSR group met in person for 90 minutes once a week. During the sessions, the study’s lead author led the teens through mindfulness exercises and facilitated group discussions, focusing on fears and stressors related to body image, as well as heart conditions and associated devices.

The online support group used Skype to connect with peers for one hour each week. During the first half of each session, Freedenberg moderated group discussions about cardiac-related health topics requested by the participants, and the last 30 minutes were spent in open discussion on any topic – often ranging from issues at school to sports and entertainment.

“We are encouraged by our initial findings, and they indicate that we need to further study and understand the impact of behavioral and psychosocial interventions in adolescents with cardiac diagnoses,” says Freedenberg. “Adult studies have shown similar interventions can reduce risk for mortality and stroke among cardiac patients, and we are hopeful that further research will show equally positive findings for teens.”

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.

Children’s National Diabetes Program Honored at SAMHSA’s National Children’s Mental Health Awareness Day

Maureen Monaghan and Fran Cogen at SAMHSA

The Substance Abuse and Mental Health Services Administration (SAMHSA) spotlighted the Children’s National diabetes program as an exemplar of integrated care for children and adolescents. Maureen Monaghan, Ph.D., CDE, (left) and Fran Cogen, M.D., CDE, interim co-chief of the Division of Endocrinology and Diabetes and director of the Childhood and Adolescent Diabetes Program, were in attendance.

On May 4, Maureen Monaghan, Ph.D., CDE, clinical and pediatric psychologist and certified diabetes educator in the Childhood and Adolescent Diabetes Program at Children’s National, participated in a panel emphasizing the importance of integrating physical and mental health in the care of young patients as part of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Children’s Mental Health Awareness Day. SAMHSA also spotlighted the Children’s National diabetes program as an exemplar of integrated care for children and adolescents.

“Many of our families start out knowing nothing about the disease, and they now have a child whose care requires day-to-day management for the rest of their lives,” says Dr. Monaghan. “It’s not a disease you ever get a break from – which can take both a physical and emotional toll on children and their families.”

Maureen Monaghan at SAMHSA National Children’s Mental Health Awareness Day

Dr. Monaghan participated in a panel emphasizing the importance of integrating physical and mental health in the care of young patients with diabetes.

To combat this issue and reduce barriers and stigma related to seeking mental health care, the program brings a dedicated, multidisciplinary care team together in one convenient location.

From the initial diagnosis, patients have access to care from a comprehensive team, including six physicians, three nurse practitioners, eight nurse educators, three psychologists, a physical therapist, dietitian and social worker. Each expert counsels the patient and the family, helping them navigate all aspects of living with the disease – from overcoming stress and anxiety to offering healthy meal-planning guides and exercise routines.

“We aren’t just concerned about how they are doing medically or what emotions they are experiencing,” says Dr. Monaghan. “Instead, our team’s integration allows us to focus on the whole child and his or her total quality of life, which is so important for patients and families with chronic disease.”

To learn more, watch this short video, featuring employees and patients of the Children’s National Childhood and Adolescent Diabetes Program, which was presented during the events surrounding the SAMHSA National Children’s Mental Health Awareness Day.

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.”