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Stopping the Cycle

Professionals work in tandem to reduce parental depression and children’s developmental delays

Even under the best circumstances, parenting can be as stressful as it is gratifying. But research indicates that when a parent is depressed, there are profound negative implications not only for the mother or father, but also for healthy child development, parent-child attachment, and family functioning. In turn, having an infant or toddler with developmental delays increases the likelihood that his or her parent will experience depression. Although these conditions often co-occur, the systems that treat them rarely intersect. Parental depression in particular often goes untreated.

“This perpetuates a cycle that affects both parent and child, particularly for low-income families,” says Kerry Reynolds, behavioral/social scientist with RAND Corporation. “Because our health systems are so siloed, childhood developmental delays and adult depression are treated by separate specialists who usually don’t think of their patient within the context of parent, child, and family functioning. This puts the health and well-being of the entire family at risk.”

Pittsburgh Responds with Collaborative Approach

Allegheny County Maternal and Child Health Care Collaborative, a broad-based community coalition in the Pittsburgh area, created an initiative to bridge the gap between the systems that were treating parents’ and children’s needs separately. The Helping Families Raise Healthy Children initiative was designed to achieve sustainable systems change to better screen and identify families at-risk for depression within the early intervention system, to improve behavioral health referral processes for those identified with depression, and increase engagement in services within both systems that incorporated a focus on the parent-child relationship.

Early in the initiative, professionals from early childhood and adult behavioral health systems received training in relationship-based models of care and learned about each other’s agencies, capabilities, and referral and intake procedures. Early intervention providers also were trained in depression screening and referral, so they could assess caregivers when working with children in their homes. All screening, referral, and follow-up behavioral health services were performed in the family’s home, as well.

“The relationship-based care training gave providers from both the pediatric and adult side common tools and language,” explains Dana Schultz, RAND Corporation senior policy analyst. RAND Corporation, a nonprofit, nonpartisan policy research organization, worked with the collaborative on implementation and training, and evaluated the initiative. “They began to think of the family context in their treatment approach, and understood that coordinating services across systems is critical.”

Positive Outcomes Spur Change

RAND’s evaluation of the initiative found that it created more collaborative approaches between early childhood intervention and adult behavioral health systems. During the evaluation period, February 2010-May 2012, more than 4,000 depression screenings were conducted, which represents 63 percent of those eligible for screening. Of parents who were identified as at-risk for depression, 62 percent received referrals for services or support. Engagement in services was very high, among those who received a referral, more than 70 percent engaged in treatment at least once. (1)

Based on the initiative’s success, depression screening, cross-system referral, and relationship-based care in both systems are continuing in Allegheny County. Other Pennsylvania counties also are beginning to implement components of the initiative to bridge their local systems of care.

Because many of the services for parents and children were provided in homes, many barriers to treatment, such as lack of transportation or child care were reduced or eliminated. Furthermore, identification of parents at risk for depression and referral processes occurred during an early childhood intervention home visit. Because early intervention personnel and behavioral health providers had opportunities to meet during the training period, the referral process was enhanced through the providers’ knowledge of and trust in one another.

“This ‘warm transfer’ strategy capitalized on the developing trust between the service provider and the parent, increasing engagement in treatment,” says Schultz. “And the direct transfer between providers who knew and trusted each other improved coordination of services.”

In addition to evaluating the initiative’s progress, RAND developed a comprehensive toolkit with step-by-step recommendations for cross-systems networking, training in relationships-based care, and implementing parental depression screening, identification and referral across systems. (2)

Wrapping Services around Families

Pittsburgh-based Alliance for Children and Families members Every Child and Holy Family Institute participated in the initiative.

Because Every Child’s doula pregnancy support and family-focused mental health service programs already provided in-home early intervention services for pregnant and postpartum women, this initiative was a natural fit. The agency also received adult behavioral health referrals when early intervention agencies screened and identified parental depression.

“Because we built this around existing services that billed through Medical Assistance, we didn’t have to find new funding streams,” says Shawn Meredith, director of child and family services at Every Child. “The training costs were minimal.”

When Every Child received a behavioral health referral, the same person worked with the parent from assessment through service provision. “Referrals need to be acted on quickly and they need to involve a single point of contact,” says Meredith.

Every Child’s doula and family-focused teams almost completely filled their referral capacity through the initiative. As Every Child saw the positive results of the program from the behavioral health side, it integrated postpartum depression screening tools into its intake process wherever applicable. It also expanded the program to families at risk of separation or working on reunification. The depression screening led to increased coordination of internal and external referrals.

“This is a hugely valuable tool. It provides a more comprehensive view of the family and really completes the circle of service provision,” says Meredith. He attributes much of the program’s success to its grassroots networking. “Not only did we develop referral sources, but we developed connections between service providers. It broke down barriers and focused on working together to get the services families needed.”

1. RAND’s full evaluation of the Helping Families Raise Healthy Children initiative is available online free of charge.
2. RAND’s toolkit is available online free of charge.

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