Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.
Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.
Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?
The role of the pediatrician
During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:
• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?
• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?
• What tools are available in primary care to accomplish this function, and how should we administer them?
Healthy Steps program evaluation
At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.
A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.
Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.
As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.
Initial results for school age, adolescent program
Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.
Future steps
Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.
Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.
