Advice for addressing mental health: Start early
Advice for addressing mental health: Start early
Thursday, March 14, 2013
Legislators considering changes to mental health policies have gotten an earful from parents who've learned the hard way how challenging the mental health system is.
They've heard about lengthy wait times to see child psychiatrists because the state doesn't have enough, how insurance doesn't always cover the services a child needs, or won't cover them until the child "fails" at less intensive programs first.
Dr. Paul Dworkin sees the crisis, too. At Connecticut Children's Medical Center, where he's physician-in-chief, there are often 12 to 15 kids in behavioral health crisis filling an emergency department that has 25 rooms.
But as Dworkin presses for those problems to be addressed, he warns that that's a "finger in the dike."
And he and others are hoping another approach to children's mental health won't get lost in the focus on fixing a crisis.
"If we're really talking about having an impact and making a difference and lessening the need, the real opportunity there is in prevention," Dworkin said.
It's possible, experts in child development say, to reduce the risk of mental health problems by focusing on the development of very young children, and by intervening early when concerns emerge, before they reach the level of diagnosable conditions.
That's in part because it's easier to find help for concerns that are identified early. At that stage, they can often be handled by community programs rather than mental health professionals who are in high demand, Dworkin said.
And it's also because of how the brain develops. Research suggests that the experiences very young children have, and their relationships with caregivers, can significantly affect how their brain circuits and other physiological processes develop. And those can have strong implications for their vulnerability to both mental and physical illnesses later in life.
"If you intervene early, it can be less costly and you can prevent more dire consequences later," said Judith Meyers, president and CEO of the Child Health and Development Institute of Connecticut. That means both addressing issues when children are young, and, with older children, dealing with problems as soon as they emerge.
"Pay now or pay later"
It's a variation of a common argument made by advocates for early childhood programs: "You pay now or you pay later." But programs with long-term payoffs don't always survive tight budgets when there are crises to fix.
The massacre at Newtown's Sandy Hook Elementary School has inspired a new focus on mental health issues. Much of the attention has gone to problems facing adolescents, young adults and adults with serious mental illnesses, although there have been some nods to the "upstream" approach Dworkin and others are advocating. A legislative panel established to help develop legislation recommended creating a task force to examine the state's mental health system, covering topics including ways to improve early intervention and treatment.
Jay Sicklick, deputy director of the Center for Children's Advocacy, said it's too soon to tell whether the response to the Sandy Hook shooting will bring increased focus on early interventions.
His organization has been pushing for behavioral health screenings to be performed at every well-child visit beginning at age 1 for children covered by Medicaid, which could help identify children with mental health issues. He said the center is working with the state Department of Social Services to make sure that children it covers receive more comprehensive annual mental health screenings.
Connecticut already has a system for kids who need services for acute mental health problems, Sicklick said.
"What doesn't exist as well is the ability to identify from an early time on, from 1 or 2 years old on, or even earlier, the kids who might be able to benefit from these early intervention services so that it doesn't blossom," he said.
Dr. Darcy Lowell, a developmental-behavioral pediatrician and professor at Yale's medical school, said she gets frustrated hearing about efforts to address mental health in adults and older children.
She supports them fully. "But I keep on having to say to people, 'Go back younger. That 5-year-old, that 6-year-old would not be in that situation if we could've found him or her at age 2,' " she said.
Toxic stress and loving parents
The focus on very young children is critical, experts say, because so much of brain development occurs in the first three years of life.
That development can be harmed by what some researchers call "toxic stress" -- prolonged and repeated exposure to stressful events such as poverty, parental mental illness, substance abuse and violence.
Prolonged exposure to toxic stress early in life affects how the body's stress-response system develops, potentially making it over-reactive or too slow to shut down when dealing with stress in the future, according to researchers at Harvard University's Center on the Developing Child.
That in turn can increase a person's vulnerability to mental and physical conditions, including depression, anxiety, substance abuse, cardiovascular disease and diabetes later in life.
"Not all children exposed to those situations will end up with high stress levels and eventually serious mental health problems," Meyers said. "But when we know that kids in those environments are high risk, that's when we start talking about interventions that will promote the resiliency and their ability to either avoid those circumstances or cope with them more effectively."
One thing that's critical to helping children cope with adverse experiences: Having a secure relationship with a nurturing adult. Studies indicate that it can protect the brain from the negative effects of stress hormones.
"This relationship becomes absolutely essential as the most important protective buffer that a child can have," Lowell said.
Lowell founded Child FIRST, a well-regarded program started in Bridgeport that works with young children and their families. More than half of the families are involved in the child welfare system, and many are referred from child care settings where the children on the verge of being expelled.
In Child FIRST, a care coordinator works with the family to get connected to services that could help. And a masters-level mental health clinician does therapy with both the child and caregiver, aiming to strengthen their relationship. That could mean helping a parent try to understand the meaning behind a child's behavior.
It could also mean helping the parent cope with his or her own experiences and how they might affect the interactions with the child. For a parent who was neglected as a child, it can be painful to hear their own child calling for help or needing attention. "It's almost like they're deaf to those kinds of cries because it is so painful to hear them, because it calls up all of this horrible experience that they had themselves," Lowell said.
A randomized controlled trial found that children in the program had fewer language and behavioral problems compared children who didn't participate. Parents had better mental health outcomes. And families in the program were significantly less likely to be involved with child protective services three years after beginning the program.
"It's almost like nurture the parents so they can nurture their child," she said. "It's difficult. It's not like it's a quick fix and it's not easy."
There are other programs that, like Child FIRST, involve visits to families' homes, which can help reduce families' isolation. There are parenting education efforts and Help Me Grow, a statewide program that can help identify children with developmental or behavioral concerns and link them to appropriate resources.
But experts say most of the programs that work haven't been brought to a large enough scale. Child FIRST, for example, operates at 10 sites in the state and will be expanding to five more, but with that expansion will have capacity for about 1,000 families a year -- "a drop in the bucket," Lowell said.
Follow Mirror health reporter Arielle Levin Becker on Twitter @ariellelb.