The third article in a four-part series.
—Sarah Eagan, Connecticut’s child advocate
New Haven – Natasha Rivera-LaButhie has logged a lot of hours in food pantries and parks, public housing complexes and libraries – anywhere to find fellow moms.
She’s there to talk to them about stress, to learn about their goals and what gets in the way of reaching them.
She’s there to help women address depression, social isolation and other things that can interfere with their capacity to nurture their children.
And she’s there to bridge a gap, between traditional mental health approaches and women they typically don’t reach.
Rivera-LaButhie is not a mental health clinician; she trained to be a cosmetologist. She uses terms like “stress” instead of “depression.”
Much about the organization she works for, The New Haven Mental Health Outreach for Mothers Partnership, or MOMS, is not traditional. For the past couple of years, it’s brought treatment to New Haven mothers – and grandmothers, aunts and other women raising children – outside clinics, in food pantries and other neighborhood locations. Next month, it will start offering mental health services in a Stop & Shop. It focuses on women’s mental health, basic needs and job skills as a way to improve outcomes for their children.
But at root, it’s trying to tackle a problem that many others in Connecticut are also trying to crack: how to apply the lessons of brain science, child development and research on early adversity to reduce children’s risks for behavioral, mental and physical health problems.
Research suggests that many mental and physical health problems have roots in exposure to trauma or other forms of severe stress early in life. And studies indicate that having a secure bond with a responsive caregiver can help young children withstand the physiological effects of adversity.
That’s led some in Connecticut to conclude that there’s a tremendous opportunity to make a dent in the prevalence of mental health problems, adult diseases – and the nation’s enormous health care tab – by focusing on young children, the circumstances they grow up in, and the relationships that can help them withstand challenges.
There are efforts to train pediatric primary-care providers to pay more attention to infants’ social and emotional development and stresses affecting their parents. The Clifford Beers Clinic in New Haven recently began a federally funded project to provide intensive care coordination – with a focus on basic needs and exposure to adversity – to children with significant medical needs and their families. It’s meant to test the theory that doing so could cut health care costs by nearly 30 percent.
Connecticut policymakers have increasingly emphasized “two-generation” policies, which focus on both young children and their parents. And there’s an effort under way to redesign the state’s health care system to better address the root causes of illness.
“Zero-to-five supports in a two-generational, effective model is the silver bullet for reducing disparities, improving health outcomes,” said Sarah Eagan, Connecticut’s child advocate. “That’s the way to improve education. It’s the way to improve economic outcomes. It’s the way to reduce health care costs.”
But those efforts are taking place in a health care system that remains largely uncoordinated, particularly when it comes to ties between mental and physical health. Home-visiting programs for families of young children, and early interventions that could help stave off deeper mental health problems, don’t have enough capacity to meet the need, according to several recent reports.
Efforts to address early childhood, particularly when it comes to mental health and family dynamics, also tread on traditionally sensitive areas, drawing concerns from some about encroaching on personal matters and the role of government in people’s lives.
And while policymakers hoping to target early trauma as a root cause of disease believe it will eventually pay off in health care savings, it remains to be seen how it will translate to savings and outcomes.
“I think what we have is a really good hypothesis,” said Kate McEvoy, Connecticut’s Medicaid director and a proponent of the idea that addressing early development and trauma can improve health outcomes and reduce costs. “We have a lot of indicators of what happens if you don’t intervene, good ideas about how to do that, and then suppositions about what the dollar level of savings is going to be.”
Paul Dworkin is among those who believe it’s possible to make a meaningful difference. But he worries about efforts to address early adversity falling into something he calls the “war-on-poverty trap,” the idea that the problem will sound too overwhelming to tackle.
“We’re not going to simply rid the world of adverse experiences,” said Dworkin, the executive vice president for community child health at Connecticut Children’s Medical Center in Hartford. “But we can focus on strengthening those protective factors that we know enable children and families to cope with stress and also ensure the best outcomes.”
Some, including the American Academy of Pediatrics, see pediatric primary care providers as the place to start.
They’re well-positioned to identify early signs of problems and provide information on healthy development, said Lisa Honigfeld, vice president for health initiatives at the Child Health and Development Institute of Connecticut. They see nearly all children in the state.
The institute provides training for medical practices on topics including trauma, maternal depression and infant mental health, which focuses on the importance of early nurturing relationships and social and emotional development.
Jerry Calnen leads that one. It’s a role he came to during three decades as a pediatrician in Enfield, where he became concerned about the growing number of children he saw with behavioral health problems. He read up on neuroscience research, and came to believe that tackling “toxic stress” – the potential consequences of a young child’s exposure to severe adversity without the presence of a supportive adult – could make a substantial difference.
“I can’t do very much about poverty or homelessness or a marital problem or something like that,” he said. “As a pediatrician, there’s not much I can do about that. But there’s a lot that I can do potentially to build resiliency, to help that infant bounce back from adverse childhood experiences.”
During a recent training, over lunch at a Danbury pediatric practice, Calnen urged the pediatricians and their staff to use screening questionnaires to identify potential issues with young children’s social and emotional development, to encourage nervous new parents and keep an eye out for things traditionally outside the realm of medicine, like family problems.
“We have to start feeling more comfortable about identifying stressors,” he said.
Yes, he acknowledged, it’s not something we’re trained for. And the answers could be daunting.
“If a mom says, ‘Yeah, I’m stressed out, I’m being evicted next month,’ what am I supposed to do?” he said. (He suggested a referral to a community agency.)
Pediatricians’ involvement with larger issues affecting their patients is often lacking, even in high-risk situations, according to a report by the Office of the Child Advocate on infants and toddlers who died of preventable causes.
The office’s review found that pediatric records rarely referenced parental risk factors like substance abuse, mental health problems or domestic violence. Pediatricians who spoke to the report’s authors cited barriers including receiving little information from the state’s child welfare agency and Medicaid payment rates that allow them to spend only about 15 minutes on each patient visit.
Even doctors who try to take a broader view of patients’ lives run into another barrier: once you uncover a problem, it’s not always easy to get help.
Dr. Rajadevi Satchi, one of the pediatricians at Calnen’s recent training, knows it firsthand. Her practice, Childcare Associates, has a system for screening patients and moms that has identified many potential issues. She watches out for domestic violence and other things that affect children. But there are few mental health services available on weekends or at night, and many parents can’t afford to take time off from work, she said. Programs in the community are often full.
“The problem we have is mental health,” she said. “Access is very difficult.”
There are efforts to change that, including a new psychiatric consultation service to help pediatricians manage behavioral health issues; efforts to train mental health providers to treat trauma; a New Haven initiative that will place mental health clinicians and consultants in a pediatric primary care clinic, Early Head Start and elementary school; and a plan to expand access to mental health services released last fall as part of legislation passed in the wake of the Newtown shootings.
And soon, there will be mental health services available at a New Haven Stop & Shop. It’s the result of years of work – and rooted in a disappointment.
Megan Smith, a professor at the Yale School of Medicine, had been developing a treatment program for mothers with depression. It was a compelling mission: a mother’s depression has been linked to significant consequences for her children, including delays in social and emotional development, lower academic achievement and an increased risk of being diagnosed with mental illness by adolescence. Depression can make it hard for a mother to provide the sort of responsive caregiving that experts say is critical for healthy development.
It’s also relatively common: more than one in 10 mothers have major depression in a given year, according to a recent study. Rates of depression symptoms are even higher among low-income women.
But no matter what Smith and her colleagues did – offering free treatment, child care, flexible hours, services in three languages – only 38 percent of the women referred for mental health care attended even one session, and only six percent stayed in treatment for six months.
“The fact that we didn’t move that needle was pretty discouraging,” Smith said.
She was facing a problem shared by many in mental health: how do you get interventions to the people who could benefit from them? How do you bridge the gap between science and low-income moms struggling with depression, trauma and other problems that affect both them and their children?
For insight, Smith and a group of community organizations sought the input of the New Haven mothers they were trying to reach. They hired local moms like Rivera-LaButhie to interview hundreds of mothers they met in supermarkets, food pantries, parks and other places.
The main findings:
“They wanted employment, and they wanted to be good moms and do well for their kids,” Smith said. “But what got in the way of those two things were, it was really stress, which is depression, [and] isolation.”
Seventy percent of the mothers who spoke with Rivera-LaButhie and her colleagues were found to have at least mild symptoms of depression on a screening. Many expressed feelings of isolation, a red flag for people in mental health.
“The more you’re isolated, the more you sort of pull away, the louder depression gets,” said Kia Levey, the MOMS Partnership’s project director.
The partnership — which is run by a group of New Haven agencies — evolved based on the feedback. It includes a focus on job training and basic needs – many moms cited not having enough food or diapers as a big source of stress.
To address depression symptoms, it offers stress-management classes, taught using a form of skill-building therapy found to be effective for depression. Rivera-LaButhie and her counterparts – known as community mental health ambassadors – lead the stress management classes with a mental health clinician. They cover things like breathing exercises and ways to solve problems without getting overwhelmed or panicking, using real-world examples.
“You burn dinner. How do you fix that?” Rivera-LaButhie said. “How do you not beat yourself up? Your light just got cut off. What are some steps to problem-solving to get the lights turned back on?”
Women bring in their own problems and have the class brainstorm ways to work on them – something that can also help counter feelings of isolation, Rivera-LaButhie said.
“We’re opening the floor for some of these moms who have never allowed feedback from anyone, not even their own family members, to get it from people that they’ve just met and to actually be able to follow through with it,” she said.
So far, 3,298 women have participated in the program. Overall, they showed clinically significant reductions in depressive symptoms, Smith said, as well as a significant drop in parenting stress and increases in positive parenting behaviors such as monitoring their children, attending routine pediatric care visits and parenting sensitivity.
Demand has grown by word of mouth – Rivera-LaButhie now spends less time out recruiting and more time answering requests – and the program is expanding, funded in part with a $3.4 million federal grant.
There’s another challenge, though: Two-thirds of mothers interviewed said they needed help coping with traumatic events. And in some ways, Smith said, getting help for trauma can be harder for the moms than addressing depression. Some women fear they will lose custody of their children if they disclose their own childhood trauma or ongoing problems, such as domestic violence or the fact that they’re “couch-surfing” to avoid homelessness, she said.
“It’s hard, and we’re still so far from doing a good job with it,” Smith said.
Kristina Stevens, an administrator at the Department of Children and Families, said the agency wants moms – and others – to feel comfortable talking about trauma.
“We know if we can’t offer up that kind of candid discussion, we’re not going to get underneath that, and that’s going to hamper the ability to do the work that’s needed to be done, to repair those situations and advance better outcomes,” she said.
Robert McLean, a New Haven internist and rheumatologist, knows that trauma can play a role in patients’ problems.
“If you’ve got somebody who’s really overweight because they have post-traumatic stress because of whatever childhood trauma they had, or they drink too much as their reaction…you’re not going to get that person to go in the right direction until you address the underlying post-traumatic issue,” he said. “There’s a lot of that.”
But the ability for doctors in busy practices to delve into those issues can be limited, McLean said.
“We’re probably not picking up stuff that’s under the surface,” he said. “I think we’re probably afraid to open up the box.”
In part, it’s because of concerns about time – what if it opens an emotional issue for a patient, and you have a few minutes and a waiting room full of people? And there’s the challenge of referring a person to appropriate mental health care.
“If you could open that box and steer them down the hall to someone, it would be different,” McLean said. ♦
Part 4: Recognition. Nelba Márquez-Greene’s family experienced a high-profile trauma when her daughter, Ana, was killed at Sandy Hook Elementary School. But before that, she understood trauma as a mental health professional. She says we need to do a better job of recognizing and responding when children need help.
Arielle Levin Becker wrote this story while participating in the National Health Journalism Fellowship, a program of USC’s Annenberg School for Communication and Journalism.