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Enhancing Home Visiting With Mental Health Consultation abstract Home visiting programs have been successful in engaging and enroll- ing families who are at high risk for stress, depression, and substance abuse. However, many of these mothers may not be receiving mental health services because home visitors lack the knowledge and skills to identify mental health or determine how to appropriately address these problems. In response, a growing number of home visiting pro- grams are expanding their capacity by integrating a mental health pro- vider into their ongoing operations. This approach, referred to as early childhood mental health consultation, involves a partnership between a professional consultant with early childhood mental health expertise and home visiting or family support programs, staff, and families. This integrated model holds the promise of promoting parent and child be- havioral health by enhancing the capacity of home visitors to identify and appropriately address the unmet mental health needs of children and families. The article highlights efforts under way in several fed- erally funded Linking Actions for Unmet Needs in Childrens Health Project sites where local programs are testing the effectiveness of this model. Pediatrics 2013;132:S180S190 AUTHORS: Barbara Dillon Goodson, PhD, a Mary Mackrain, MEd, b Deborah F. Perry, PhD, c Kevin OBrien, LMFT, LCSW, d and Margaret K. Gwaltney, MBA e a Dillon-Goodson Research Associates, Westeld, Massachusetts, b Education Development Center, Newton, Massachusetts, c Georgetown University Center for Child and Human Development, Washington, District of Columbia, d Aurora Family Service, Milwaukee, Wisconsin, and e Abt Associates Inc, Bethesda, Maryland KEY WORDS mental health consultation, home visiting, evidence-based practice, behavioral health, pediatric medical home ABBREVIATIONS Project LAUNCHLinking Actions for Unmet Needs in Childrens Health SAMHSASubstance Abuse and Mental Health Services Administration Dr Goodson was involved in the conceptualization and design of the paper, drafted the initial manuscript, and revised the manuscript in response to reviewerscomments; Ms Mackrain and Dr Perry were involved in the conceptualization and design of the paper, drafted key sections of the manuscript, and revised the manuscript in response to reviewerscomments; Mr OBrien was involved in the conceptualization and design of the paper, and provided data for and drafted portions of the manuscript; Ms Gwaltney was involved in the conceptualization and design of the paper, critically reviewed the manuscript, and revised the manuscript in response to reviewerscomments; and all authors approved the nal manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2013-1021S doi:10.1542/peds.2013-1021S Accepted for publication Aug 26, 2013 Address correspondence to Barbara Dillon Goodson, PhD, Dillon- Goodson Research Associates, 409 Montgomery Road, Westeld, MA 01085. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose. FUNDING: The US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration is the funding source for the Linking Actions for Unmet Needs in Childrens Health program. Funding for the cross-site evaluation of the Linking Actions for Unmet Needs in Childrens Health program is provided to Abt Associates, Inc, through a contract with the Administration for Children and Families. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of interest to disclose. S180 Goodson et al by guest on August 10, 2018 www.aappublications.org/news Downloaded from

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Enhancing Home Visiting With Mental HealthConsultation

abstractHome visiting programs have been successful in engaging and enroll-ing families who are at high risk for stress, depression, and substanceabuse. However, many of these mothers may not be receiving mentalhealth services because home visitors lack the knowledge and skills toidentify mental health or determine how to appropriately addressthese problems. In response, a growing number of home visiting pro-grams are expanding their capacity by integrating a mental health pro-vider into their ongoing operations. This approach, referred to as earlychildhood mental health consultation, involves a partnership betweena professional consultant with early childhood mental health expertiseand home visiting or family support programs, staff, and families. Thisintegrated model holds the promise of promoting parent and child be-havioral health by enhancing the capacity of home visitors to identifyand appropriately address the unmet mental health needs of childrenand families. The article highlights efforts under way in several fed-erally funded Linking Actions for Unmet Needs in Children’s HealthProject sites where local programs are testing the effectiveness ofthis model. Pediatrics 2013;132:S180–S190

AUTHORS: Barbara Dillon Goodson, PhD,a Mary Mackrain,MEd,b Deborah F. Perry, PhD,c Kevin O’Brien, LMFT, LCSW,d

and Margaret K. Gwaltney, MBAe

aDillon-Goodson Research Associates, Westfield, Massachusetts,bEducation Development Center, Newton, Massachusetts,cGeorgetown University Center for Child and HumanDevelopment, Washington, District of Columbia, dAurora FamilyService, Milwaukee, Wisconsin, and eAbt Associates Inc, Bethesda,Maryland

KEY WORDSmental health consultation, home visiting, evidence-basedpractice, behavioral health, pediatric medical home

ABBREVIATIONSProject LAUNCH—Linking Actions for Unmet Needs in Children’sHealthSAMHSA—Substance Abuse and Mental Health ServicesAdministration

Dr Goodson was involved in the conceptualization and designof the paper, drafted the initial manuscript, and revised themanuscript in response to reviewers’ comments; Ms Mackrainand Dr Perry were involved in the conceptualization and designof the paper, drafted key sections of the manuscript, and revisedthe manuscript in response to reviewers’ comments; Mr O’Brienwas involved in the conceptualization and design of the paper,and provided data for and drafted portions of the manuscript;Ms Gwaltney was involved in the conceptualization and design ofthe paper, critically reviewed the manuscript, and revised themanuscript in response to reviewers’ comments; and allauthors approved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1021S

doi:10.1542/peds.2013-1021S

Accepted for publication Aug 26, 2013

Address correspondence to Barbara Dillon Goodson, PhD, Dillon-Goodson Research Associates, 409 Montgomery Road, Westfield,MA 01085. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: The US Department of Health and Human Services,Substance Abuse and Mental Health Services Administration isthe funding source for the Linking Actions for Unmet Needs inChildren’s Health program. Funding for the cross-site evaluationof the Linking Actions for Unmet Needs in Children’s Healthprogram is provided to Abt Associates, Inc, through a contractwith the Administration for Children and Families.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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There is a growing consensus that manychronic health and developmental mor-bidities are the product of a complexinteraction of biological, psychosocial,and environmental influences.1 Recentdiscoveries in neuroscience, for exam-ple, point to the cumulative impact ofadverse childhood experiences on thedevelopment of a broad range of laterconditions.2 Children exposed to ongoingadverse experiences can face prolongedstress, often referred to as “toxic stress,”which puts them at risk for changes inthe architecture and later functioning oftheir brains and immune systems.3

These child risk factors may arise fromdynamics in their own families, includingmaternal depression and clinical andsocial correlates of this depression:trauma and intimate partner violence,poor birth outcomes, and infant mor-tality.4 Maternal depression, oftenunderdiagnosed and untreated in thefirst several years of life, is a particularlyprevalent concern, with estimates rang-ing from 15% in the general populationto double that in low-income mothers.5

As pediatric providers begin to in-corporate the latest findings from neu-roscience into their efforts to establishhigh-quality medical homes for theirpatients, they find themselves servingmany families who may be at risk fortoxic stress and who are experiencingpsychosocial challenges. However, pedi-atricians and primary care providersoften report not having enough knowl-edge to detect and manage mentalhealth problems in young children andto make referrals for mental healthprevention and treatment services.5

Pediatric primary care practices cantake steps to care for young childrenwith mental health problems, as well asnormalizing and destigmatizing mentalhealth, by engaging families in com-munity services like home visitation.6

Home visitation programs are oftendesigned to serve families and youngchildren who are at heightened risk,

including families living in poverty,teenage and single parents, and fami-lies at risk for child maltreatment.

In one study of a Healthy FamiliesAmerica home visiting program, almost30% of mothers enrolled screenedpositive for depression, and about 70%reported experiencing at least 1 violenttrauma in their lives.7 Furthermore,although estimated rates of depres-sion among pregnant, postpartum, andparenting mothers range from 5% to25%,8 a review of studies revealed thatbetween 28% and 61% of mothers en-rolled in home visiting programs wereidentified with depression.7 Experi-ences of depression, substance abuse,or intimate partner violence in preg-nant women have been found to con-tribute to low birth weight, pretermbirths, increased pain and discomfortduring pregnancy and childbirth, andhigher levels of stress.9

At the same time that home visitingprograms appear to be reaching someof the most vulnerable families, evi-dence exists that home visitation pro-grams alone may not be sufficient toaddress all of the mental health needsof the families they serve. A study of aninitiative that implemented 4 homevisiting models (Healthy Start, HealthyFamilies America, and 2 locally de-veloped models) found that fewer than25% of women with depressive symp-toms receivedmental health services inthe6monthsafterenrollment inahomevisiting program.10 Focus groups withhome visitors suggest that trainingmay not equip home visitors to addressthe mental health, substance abuse,and domestic violence in the familiesthey serve.11,12

INTEGRATION OF EARLYCHILDHOOD MENTAL HEALTHCONSULTATION AND HOMEVISITING

Inresponsetothesechallenges,agrowingnumber of home visiting programs are

expanding their capacity to serve high-risk families by integrating a mentalhealth provider into the ongoing oper-ations of their programs. These ap-proaches, referred to as early childhoodmental health consultation, involve apartnership between a professionalconsultant with early childhood mentalhealth expertise and home visitingprograms,staff, and families; themodelsare similar to the integration of mentalhealth consultation in early care andeducation settings, which has yieldedpromising results over the past de-cade.13 In home visiting, the mentalhealth consultation is designed to buildthe capacity of the home visitors torecognize, interpret, and support theindividual socioemotional needs ofchildren and families in their care, es-pecially when there are mental healthconcerns, and to support families increating home environments that arepositive climates for children’s learningand growth.14 Mental health consulta-tion can involve multiple types of sup-port for home visitors, includingconsultation about the individual needsof children and families, professionaldevelopment on mental health–relatedtopics, and group and one-on-one re-flective supervision. Reflective supervi-sion provides home visitors withongoing and regular opportunities forreflection to sort out and cope withstrong feelings brought on by complexwork with families.15–19 Reflective su-pervision also allows the home visitor toexperience the same high-quality, sup-portive relationship that he or she isexpected to provide for infants, tod-dlers, and families.15

Integrating mental health consultationintohomevisitingprograms isbasedona set of expectations about how pro-grams can enhance their intendedeffects on parents and children served.Figure 1 provides a schema depictingseveral presumed pathways by whichmental health consultation integrated

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into home visiting programs might en-hance outcomes for parents and chil-dren. The primary pathway is throughthe home visitors: mental health con-sultation provides information andsupport that are intended to equiphome visitors with additional skills andto increase their effectiveness at help-ing families deal with parental or childmental health issues. This could im-prove not only children’s socioemotionaloutcomes but, potentially, other out-comes, if mental or behavioral healthissues have been barriers to otheraspects of child learning and de-velopment. A second potential pathwayto improved parent and child out-comes is through improved identifi-cation of behavioral health problemsand facilitated referral to treatment orbrief intervention, which can lead toincreased capacity for positive par-enting, healthy parent/child inter-actions, and healthy child functioning.A third pathway is through increasedjob satisfaction and reduced job stressfor home visitors, which is hypothe-sized to increase effectiveness inworking with the families they serve. Afourth pathway shown on the logicmodel is through a potential strength-ening of the quality of implementationof the home visiting program (eg,stronger fidelity of implementation). Iffamilies receive help in addressingtheir mental health concerns, theymay engage more fully with the homevisitor who, in turn, may be better ableto implement the planned strategiesfor improving family and child out-comes.

This developing approach in home vis-iting is particularly noteworthy in lightof the rapid expansion in the number offamilies and children with access tohome visitation services. Of the morethan4millionbirths in theUnitedStateseach year, an estimated 400 000 infantsand their families currently receiveintensive home visitation services.20

This number is expected to increaseover the next 5 years, as states expandtheir evidence-based home visiting pro-grams with funding provided by thePatient Protection and Affordable CareAct. This legislation provides $1.5 bil-lion in new federal dollars for the Ma-ternal Infant and Early Childhood HomeVisiting program.

MENTAL HEALTH CONSULTATION INHOME VISITING PROGRAMS IN THELINKING ACTIONS FOR UNMETNEEDS IN CHILDREN’S HEALTHPROJECT

Since 2009, the Substance Abuse andMental Health Services Administration(SAMHSA) has been promoting behav-ioral health and prevention of futuremental health problems in young chil-dren (prenatal to 8 years) and theirfamilies through its Project LAUNCH(Linking Actions for Unmet Needs inChildren’s Health) grant program. Pro-ject LAUNCH provides funding to 35states, tribal nations, and local com-munities to implement evidence-basedprograms that represent 5 broad pre-vention and promotion strategies: en-hanced home visitation, family educationand support, developmental screeningand assessment, early childhood men-tal health consultation, and integrationof behavioral health in primary care.

The mandate of Project LAUNCH hasbeen an impetus for the LAUNCH com-munities to integrate physical and be-havioral health services and supportsfor children and their families. Oneconsequence has been that a growingnumber of Project LAUNCH granteeshave opted to develop innovative mod-els that integrate early childhoodmental health consultation into existinghome visitation services. This in-tegrated model holds the promise ofpromoting parent and child behavioralhealth by enhancing the capacity ofhome visitors to identify and appro-priately address the unmet mental

health needs of children and families.Additionally, these integration effortsare helping communities align withfederal Project LAUNCH guidelines toenhance existing services, rather thansupplant funds, and, in the case of thenew federal home visiting program,Maternal Infant and Early ChildhoodHome Visiting, grantees are chargedwith supporting efforts to meet thebenchmarks for high-quality imple-mentation.

Project LAUNCH grantees are alsoimplementing mental health consulta-tion in primary care settings. Here, themotivation is the same: to give theprimary care providers who are caringfor young children and families withmental or behavioral health concernsaccess to trained mental health con-sultants. These consultants can providescreening, assessment, and consulta-tion to the primary care providersabout individual children and partici-pate in developing a referral plan forappropriate services.

PROJECT LAUNCH HOME VISITINGMODELS AND THE RISK PROFILEOF FAMILIES IN HOME VISITINGPROGRAMS

Among the Project LAUNCH granteesfunded between 2009 and 2011, 8 areimplementing early childhood mentalhealth consultation within 12 homevisiting programs. Table 1 describesthe program objectives, eligibilitycriteria, and staffing for these 12programs. Data collected by granteeson the families who participated inthe home visiting programs showthat families experience multiplestresses that pose risks to children.On average, most mothers in thehome visiting programs are single(63%) and lack a high school educa-tion (55%); in addition, 41% of themothers are unemployed and 46%are teens. Forty-four percent of themothers experience at least 3 of

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above risk factors. In terms of psy-chosocial risks, 16% of the familiesare identified as having someone inthe household with mental illness,and 11% report that someone in thefamily is the victim of domesticabuse.

Features of Mental HealthConsultation in Project LAUNCH–Supported Home VisitingPrograms.

The 8 Project LAUNCH sites are imple-mentingmultiple types ofmental healthconsultation activities in their homevisiting programs, some that involvesupport to the home visiting staff andothers that involve direct work withfamilies. As shown in Table 2, in all sitesthe consultants provide reflective su-pervision, both one-on-one and tohome visiting staff as a group.

A second type of support provided bythe mental health consultant is collab-oration with home visitors related toconcernsabout a specific child or family,

often referred to as child/family theabove consultation.15 This involves work-ing with home visitors to help them de-velop strategies to assist families that donot meet criteria for immediate crisisintervention but whose well-being is ofconcern.

A third common type of support is theconsultant providing information andtraining to home visitors on mentalhealth topics. For example, as reportedby Project LAUNCH sites, mental healthconsultants have provided training tohome visitors on strategies for man-aging their own stress and trauma,strategies for identifying mental healthissues in parents and children andreferral resources in the community,the developmental importance of earlymother-child attachment, and addressingattachment disorders. Project LAUNCHsites use different approaches to thiscollaboration, ranging from consulta-tion with a home visitor by telephone,to individual discussions outside thehome setting, to accompanying home

visitors on family visits. The following isan example of this type of supportprovided by one of the Project LAUNCHenhanced home visiting programs:

A home visitor was working with apregnant mother facing many complexchallenges, including anxiety, severedepression, and domestic violence inthe home. The mother had 2 childrenliving with her, ages 2 and 6, as well asa 9-year-old living in Mexico. ChildProtective Services had opened an in-quiry in the home because of concernsabout abuse with the 6-year-old child,yet determined a formal case was notwarranted, a cause of concern for thehome visitor. Unsure of her options, thehome visitor turned to the mentalhealth consultant who helped her toreduce her anxiety, gain perspective,and focus on what they could accom-plish with the family. Working together,they developed a plan of action, whichincluded follow-upwith Child ProtectiveServices, as well as an array of refer-rals for additional services to provide

FIGURE 1Integration of mental health consultation into home visiting: presumed pathways for achieving outcomes for parents and children.

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TABLE1

HomeVisitingModelsSupportedWithin

8ProjectLAUN

CHGrantees

IntegratingMentalHealth

Consultation

ProjectLAUNCHGrantee

NameofHomeVisiting

Program/M

odel

Core

ComponentsofHome

VisitingProgram/M

odel

EligibilityCriteriaEstablishedby

HomeVisitingProgram/M

odel

Ages

ofChildreninHome

VisitingProgram/M

odel

Characteristics

ofHomeVisitors

EastOakland,CA

ImprovingPregnancyOutcom

esProgram(IP

OP)(county

publichealth

department)

Medicalcase

managem

ent

Low-incomepregnant

andparentingAfrican

American

wom

en,m

en,and

theirinfants

Prenatal–2y

Publichealth

nurses;

BA-levelcasemanagers,

community

health

outreach

workers

Maternaland

child

health

Developm

entalscreening

andreferrals

Child

developm

ent

BlackInfant

Health

(BIH)(county

publichealth

department)

Low-incomepregnant

andparenting

AfricanAm

erican

wom

en,m

en,

andinfants#18

mo

20wk(10prenatal

and10

postnatal)

Your

Family

Counts(county

publichealth

department)

Maternaland

child

health

Medicallyor

sociallyat-identified

risk

forpoor

maternalpregnancy

outcom

esPrenatal–1y

Developm

entalscreening

andreferrals

Child

developm

ent

WeldCounty,CO

Parentsas

Teachers

(PAT)a

(com

munity

behavioral

health

program)

Child

developm

ent,Child

health

andsafety

Families/guardians

with

$1risk

factor:

isolation,poverty;educationofparent;

language

barriers;developmentaldelays;

parent

with

mentalhealth

and/or

developm

entaldelay

Birth–5y

Degreedprofessionals

(BAor

MAlevel)

Developm

ental,hearing,

vision

andreferrals

Family

resiliencyand

protectivefactors

Community

resourcesandsupport

NewBritain,CT

Child

FIRST

Parent-childrelationship

Families

with

youngchildrenwho

areat

risk

fordevelopm

entaldelaysor

emotionaldisturbance

0–6y

Child

FIRSTTeam

=OneBA

Care

Coordinatorand

oneMA/Licensed

Mental

Health

Clinician

Strengtheningfamily

supportsand

connectingtocommunity

resources

WashingtonCounty,M

EBridging

Program(com

munity

collaborative)

Infant/childhealth

andnutrition

Wom

enwho

have

infantsor

youngchildren

with

multipleneedsand/or

wom

enwith

high-riskpregnancies.Child

need

include

babies

born

preterm,infantstreatedfor

medicalissues

intheNICU,infantsand

youngchildrenwith

high

risk

factors

ormedicalanddevelopm

entalissues,

aswellasparentswho

need

extrasupport

tomeetthe

needsoftheirchild.

Prenatal–8y

Publichealth

nurses

orMAlevel

Child

safety

Services

provided

until

family

isstabilizedandthen

transferredtoless-intensive

homevisitingprogram

Child

grow

thanddevelopm

ent

Community

resourcesandsupport

SantaFe,NM

FirstB

ornHomeVisitingProgram

(UnitedWay

ofSantaFe)

Maternalprenatal

First-timeparents

Prenatal–3y;Families

enroll

prenatallyandreceive

visitsup

tothechild’s

thirdbirthday

Clinicallytraineddegreed

andnondegreed

professionalsc

Postnatalm

aternaland

child

physicalandmentalhealth

Infant

grow

thanddevelopm

ent

(including

bondingand

attachment)

Child

safety

Stimulatinghomeenvironm

ent

Access

tocommunity

resources

andsupport

S184 Goodson et al by guest on August 10, 2018www.aappublications.org/newsDownloaded from

TABLE1

Continued

ProjectLAUNCHGrantee

NameofHomeVisiting

Program/M

odel

Core

ComponentsofHome

VisitingProgram/M

odel

EligibilityCriteriaEstablishedby

HomeVisitingProgram/M

odel

Ages

ofChildreninHome

VisitingProgram/M

odel

Characteristics

ofHomeVisitors

NewYork

City,NY

Nurse-Family

Partnership

Program(NFP)a

Healthypregnanciesandinfants

First-timemother,28

wkpregnant

orless,low

income

Prenatal–2y

Publichealth

nurses

Child

health,development,

andscreening

Families

have

the

opportunity

toparticipate

for2+

y(until

child’ssecond

birthday)

Family

socialsupportand

econom

icself-sufficiency

Parent-infant

attachmentCommunity

resourcesandsupport

Multnom

ahCounty,OR

HealthyStart∼HealthyFamilies

Oregon–HealthyFamilies

Americaa

Preventionofchild

abusethrough

improved

parent-childrelationship

First-timemothers

0–3y

BA-levelprofessionals

Family

stability

Atleast2risk

factors,or

depression

orsubstanceabuse

Families

typically

participate

for6–12

mo

Schoolreadiness

Healthychild

developm

ent

Milw

aukee,WI

EmpoweringFamilies

ofMilw

aukee—

includes

HealthyFamilies

America,

PATa(city

publichealth

department)

Improved

birthoutcom

esMothers

atrisk

forpoor

birthoutcom

esPrenatal–age3

Socialworker(BSW

/MSW

)or

community

health

workerandpublic

health

nurseteam

Infant

andchild

health

Families

enrollprenatallyand

receivevisitsuntilchild’s

thirdbirthday

Child

Safety

Child

grow

thanddevelopm

ent

Family

functioning

NFPa

(city

publichealth

department)

Improved

pregnancyandbirth

outcom

esFirst-timepregnant

teensand

wom

en,28

wkpregnant

Prenatal–2y

Publichealth

nurses

Child

health

anddevelopm

ent

Families

enrollprenatallyand

receivevisitsuntilchild’s

second

birthday

Family

econom

icself-sufficiency

HomeInstructionforParentsof

PreschoolYoungsters(HIPPY)a

(COA

bYouthandFamily

Centersa)

Parent

involvem

ent

Resident

ofMilw

aukee

3–5y

Parents

Schoolreadiness

Programoperates

foraschool

year

(30wk),and

families

can

participatemultipletim

eswhen

child

isbetweenages

3and5

BA,bachelor’s

degree;BSW

,bachelor’s

degree

insocialwork;MA,master’s

degree;M

SW,m

aster’s

degree

insocialwork.

aEvidence-based

programmodel.

bCOA(the

Community

OutingAssociation)

isanonprofitagencysupportingsocialserviceandeducationalprojectsinMilw

aukee.

cProgrammodelspecifies

thathomevisitors

arepublichealthnurses;because

thereisashortsupplyofclinicallytrainedstaffinthecounty,inSantaFe,the

homevisitors

areamixofbachelor’sdegree

andnon-BA

staffw

ithexperience

insocial

services.

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TABLE2

Features

ofMentalHealth

ConsultationActivities

Integrated

inProjectLAUN

CHHomeVisitingPrograms

ProjectLAUN

CHGrantee/HomeVisiting

Program/Model

Qualifications

ofMHC(s)

SupportsProvided

byEarlyChildhood

MHC

WithinHomeVisitationPrograms

Approach

toReflectiveSupervisiona

FrequencyofMeeting

With

HomeVisitors

for

ReflectiveSupervision

Child/Fam

ily-Centered

ConsultationActivities

bEstim

ated

No.of

Families

forWhom

MHC

Collaborated

With

HomeVisitor

One-on-One

Therapyfor

Client

(Traditional

Therapy)

Estim

ated

%of

Consultant

Time

inOne-on-One

Therapy

(PastYear)

Workforce

Developm

ent

onSpecificBirth-8Child

andFamily

Mental

andBehavioralHealth

Topics

EastOakland,CA

Licensed,m

aster’s-

levelclinician

Groupstaffm

eetings

and

one-on-one

consultation

Groupsessions,on

average,6tim

espermonth

andhas

atleast6

individual

consultations

permonth

One-on-one

form

alandinform

alcase

consultationand

referrals

2–3families

permonth

Short-term,

immediate,

individualand

grouptherapyd

20%oftim

eEducateproviderson

key

mentalhealth

topics

(eg,

childhood

trauma,

buildinghealthy

relationships,dom

estic

violence,depression,

substanceabuse,

immigration,anxiety)

Partnerwith

providers

toco-facilitate

inclient

groups

onmental

health

them

esWeldCounty,CO

Licensed,m

aster’s-

levelclinician

Groupstaffm

eetings

and

one-on-one

consultation

2–4tim

espermonth

Yes

20Ifneeded

c10%oftim

eYes

NewBritain,CT

Licensed,m

aster’s-

levelclinician

Groupstaffm

eetings

and

one-on-one

consultation

2–4tim

espermonth

Yes

10No

0Yes

Washington

County,M

ELicensed

master’s-

levelclinician

Groupstaffm

eetings

and

one-on-one

consultation

Monthlyindividualand

groupsupervision

Byphone,on

anas-

needed

basis

6families

permonth

Notp

rovidedc

0Driven

byneedsthat

ariseas

partof

supervision

SantaFe,NM

Licensed,m

aster’s-

levelclinician

Groupstaffm

eetings

and

one-on-one

consultation

asneeded

Weeklyindividual

supervision

Yes

Estim

ated

3–4

families

permonth

Notp

rovidedc

0Twoseminars

Weeklygroup

supervision

NewYork

City,NY

Licensed,doctoral-

levelclinician

Groupreflective

supervisionand

didacticpresentations

ontopics

generated

bythenurses.

2tim

esamonth

Case

consultation

andreflective

guidance

tonurses

aboutspecific

families

ingroup

reflectivesupervision,

identificationand

referral

39(m

aybe

duplicated

across

quarters)

Notp

rovidedc

0Didactictraining

topics

arisefrom

groupand

have

included

toxic

stress,m

aternal

depression,toddlerhood,

temperament,and

defensemechanism

s

Multnom

ahCounty,OR

Licensed,m

aster’s-

levelclinician

Groupreflective

supervision

Ininitialphase

Yes

150–160inayear

Notp

rovidedc

0PBISetrainingsfocused

onhomevisiting

Milw

aukee,

WI:Nurse-

Family

Partnership

Program

Licensed

master’s-

levelclinician

Groupstaffm

eetings

andone-on-one

interactions

Monthly

Case

review

s7

Notp

rovidedc

0Introductionto

MHC

Telephoneand

E-mailsupport

Motivationalinterview

ing

Collaborative

homevisits

Compassionfatigue

Referralsources

provided

Boundary

settingHome

visitingsupervisor

engagedinreflective

supervisiontraining

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TABLE2

Continued

ProjectLAUN

CHGrantee/HomeVisiting

Program/Model

Qualifications

ofMHC(s)

SupportsProvided

byEarlyChildhood

MHC

WithinHomeVisitationPrograms

Approach

toReflectiveSupervisiona

FrequencyofMeeting

With

HomeVisitors

for

ReflectiveSupervision

Child/Fam

ily-Centered

ConsultationActivities

bEstim

ated

No.of

Families

forWhom

MHC

Collaborated

With

HomeVisitor

One-on-One

Therapyfor

Client

(Traditional

Therapy)

Estim

ated

%of

Consultant

Time

inOne-on-One

Therapy

(PastYear)

Workforce

Developm

ent

onSpecificBirth-8Child

andFamily

Mental

andBehavioralHealth

Topics

Providesupportin

addressing

screeningresults

Milw

aukee,WI:

Empowering

Families

ofMilw

aukee:

HealthyFamilies

America,Parents

asTeachers

(PAT)

Licensed

master’s-

levelclinician

Groupstaffm

eetings

andone-on-one

interactions

Monthly

Case

review

s43

Notp

rovidedc

0Introductionto

MHC

Telephoneand

E-mailsupport

Motivationalinterview

ing

Collaborative

homevisits

Compassionfatigue

Referralsources

provided

Boundary

setting

Providesupportin

addressing

screeningresults

Homevisitingsupervisor

engagedinreflective

supervisiontraining

HIPPY

Licensed

master’s-

levelclinician

Groupstaffm

eetings

andone-on-one

interactions

Monthly

Case

review

s19

Notp

rovidedc

0Introductionto

MHC

Telephoneand

E-mailsupport

Mandatory

reporting

Collaborative

homevisits

Referralsources

provided

HIPPY,HomeInstructionforParentsofPreschoolYoungershomevisitingprogrammodel;M

HC,m

entalhealth

consultant.

aReflectivesupervisionreferstotheMHC

working

with

homevisitorstobuild

capacityandproblem-solving

skillsaround

family/childmentalhealth

concerns;although

reflectivesupervisionmay

involvediscussion

ofspecificfamilies,the

focusisless

onproblemsolvingabouta

particular

family

andmoreon

thedevelopm

entofthe

homevisitors’ownskillsandstrategies

forworking

with

families

tosolveproblems.Itisintended

tocreatean

environm

entcharacterized

bysafety,calmness,and

support,in

which

supervisor

andsupervisee

exploretherangeofem

otions

(positive

andnegative)relatedtothefamilies

andissues

thesupervisee

ismanaging.Theroleofthesupervisor

istohelpthesupervisee

toansw

erhisor

herow

nquestions,and

toprovide

thesupportand

know

ledgenecessarytoguidedecision

making.Inaddition,thesupervisor

provides

anem

pathetic,nonjudgmentalear

tothesupervisee.W

orking

throughcomplex

emotions

ina“safeplace”allowsthesupervisee

tomanagethestress

heor

sheexperienceson

thejob.21

bCollaborationwith

homevisitorsinworking

with

individualfamilies

with

family/childconcerns.M

ayaccompany

homevisitorson

visitstofamilies

(1–3tim

es/fam

ily),may

jointly

developreferralplan,based

oninform

ationinconsultationinterviewwith

family,child/parentscreening.TheMHC

andhomevisitors

sharesomelevelofresponsibilityforoutcom

esforfamily,but

theMHC

isnottheprimaryclinicianor

therapisttofamily;the

MHC

hasamoreindirectrole.

cInmostofthe

ProjectLAUNCHsites,thehomevisitingprogramspurposelydo

notrefer

families

totheMHC

fortherapy,outofconcern

thatthiscouldaltertheobjectiveofmaintaining

theprimaryrelationshipbetweenthefamily

andthehomevisitor.

Exceptions

have

been

made,however,w

hentheMHC

hasbeen

abletoforgeabridge

totreatm

entthroughbuildingtrustduring

abriefinterventionwith

afamily

that

was

reluctanttoaccess

traditionalmentalhealth

services.

dInthisproject,theMHC

takeson

theroleofprovidingbrieffam

ilytherapy,motivated

largelyby

theprogram’srecognition

ofthenearlycompletelack

ofmentalhealth

services

inthecommunity.Treatmentincludesdyadicworkwith

newmothers

with

bondingdifficulty

with

theirinfantrelatedtoprevious

traumaor

depression;treatmentofsituationaldepressionoftenrooted

inprevious

trauma,issues

ofchild

abuse,or

substanceabuse;treatm

entofgeneralized

anxietyoftenbroughtonby

birthofthe

child

andrelatedtoprevious

traumaor

depression,and

perceivedlack

ofsupport;grouptherapyfocusedon

psycho-educationalcorefactorsofresiliency,attachment,healing,healthyrelationships,buildingacommunity

ofsupport,andhowtoprotect

them

selves

andtheirchildren.

ePBIS=PositiveBehavior

Interventions

andSupports,anapproach

thatuses

atieredpreventionfram

eworkforyoungchildren;basedon

a“teachingpyramid”representsacontinuumofsupportsandservices

designed

toprom

otesocioemotional

competenceandaddresschallengingbehaviorsinyoungchildren.

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mental health, health, social, and medi-cal supports to the family. Unfortunately,cases such as these are common andthe mental health consultant playsakey role insupportinghomevisitors inaddressing complex family situations(ShinkleJ, EastOaklandProject LAUNCH,unpublished observations, 2012).

EVALUATING INTEGRATION OFMENTAL HEALTH CONSULTATION INHOME VISITING

Project LAUNCH has been a platform forinnovative models of early childhoodmental health consultation in homevisiting. If this integrated model con-tinues to develop as an approach inhome visiting, the field will need addi-tional research first on the imple-mentation of themodel, and, second, onits effects, to provide the evidence thefield needs to build quality standardsfor this approach. Comprehensive im-plementation studies are needed toilluminate how mental health consul-tation can be integrated with differentevidence-based home visiting models.Then, rigorous impact evaluationsshould be conducted on the value-added of integrating mental healthconsultation into home visiting forhome visitors and the families andchildren they serve. One of the unan-swered questions concerns the impactofmental health consultation on fidelityof implementation for evidence-basedhome visiting models: on the one hand,model developers have expressed con-cern that adding mental health con-sultants coulddetract from local effortsto adhere to the model specifications.On the other hand, as depicted in thelogicmodel, mental health consultationcouldresult inbetteradherence, throughincreased engagement of hard-to-reachclients, greater likelihood of deliveringthe intended content, and reductions instaff turnover.

Initial findings are promising. Somestudies have reported evidence that

home visitors with access to a men-tal health consultant have decreasedstress levels, lessened rates of “com-passion fatigue,” and reported an in-crease in professional growth, comparedwith home visitors who do not haveconsultation.22–24 Furthermore, Borisand colleagues25 showed excellent fea-sibility of augmenting nurse home vis-itors with a mental health consultantwho assisted with issues related topostpartum depression, domestic vio-lence, and the impact of these riskfactors on maternal-child interaction.Ammerman and colleagues26 have de-veloped and implemented a model ofhome visitation for depressed mothersthat includes home-based mentalhealth clinicians working in collabora-tion with home visitors. This augmen-tation of home visitation has helpedhome visitors facilitate successful re-ferrals, along with mothers’ active en-gagement with services.

Within Project LAUNCH, preliminaryfindings based on self-reports of homevisitors are encouraging. As part ofthe local evaluations in each of theProject LAUNCH sites, home visitors areasked about changes in their knowledgeand practice associated with ProjectLAUNCH–funded activities. Responsesfrom home visitors in 6 programs inwhich mental health consultation hadbeen in place for at least a year showedthat nearly 90% of the home visitorsreported change in their knowledge ofchildren’s socioemotional and behav-ioral health and development, and ofavailable options for follow-up servicesfor children with behavioral healthissues (Goodson, BD, Gwaltney, MK,Walker, DK. Cross-Site Evaluation ofProject LAUNCH: Interim Findings.Washington, DC: Office of Planning, Re-search and Evaluation, Administrationfor Children and Families, U.S. De-partment of Health and Human Ser-vices; in review). Additional qualitativedata from these Project LAUNCH sites

support the notion that these changesin knowledge resulted from collabora-tion with the mental health consultants.In the words of 3 home visitors:

My mental health consultant has spe-cialized knowledge and skills that I don’thave. She has helped me to see thingsthat I didn’t pick up on. She really fo-cuses on engagement of the family inthe process. And those are specializedskills that, again, most teachers, nurses,even social workers aren’t taught toaddress—such as readiness for changeand motivation and things that might beblocking a family’s engagement. I’m notdiagnosing, but now I pick up on possibleundiagnosed problems. [Home visitor,Project LAUNCH]

I am able to focus more on secure at-tachment, discipline, and toddler be-havior than I was before I had help froma mental health consultant. My obser-vational skills of parent/child interactionhave improved. [Home visitor, ProjectLAUNCH]

With support from my mental healthconsultant, I now pay more attention toa family’s mental health issues. It makesworking with families easier becausethe mental health consultant helps to de-stigmatize mental health needs. We areworking more with families on mentalhealth issues, and providing referrals (tomental health consultation, as well asother services). As a result of mentalhealth consultation, I am more skilled atassessing needs and have new ways tosee and understand the complexities ofmental health and well-being in families.[Home visitor, Project LAUNCH]

RECOMMENDATIONS AND NEXTSTEPS

Home visiting and pediatric practicesshare common goals and are serving thesame clients at a critical time in the livesof young children and their families.27

Families who are experiencing risk fac-tors, especially maternal depression,can benefit from enhanced collaborationbetween their pediatricians and homevisiting programs.5 In primary carepractices that are conducting routinescreening for maternal depression,home visiting programs, especiallythose with enhanced mental healthconsultation, can be an excellent placefor ongoing support to families who

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exhibit depressive symptoms. Moth-ers with depression and familiesdealing with toxic stressors may beunlikely on their own to follow throughon health promotion and preventionsuggestions provided by the pediatri-cian. However, by linking with homevisiting programs, pediatric practiceshave access to home visitors who canreinforce guidance from pediatricians,prepare parents for an anticipated de-velopment, and facilitate a family’s useof appropriate ancillary services.28

Thus, home visiting programs that pro-videmental health consultation to homevisitors represent a potential resourcefor pediatricians who themselves maynot be able to meet the needs of thegrowing population of children andfamilies with mental health issues. Theexistence of these enhanced home vis-iting programs may increase the pedi-atric community’s ability to connectfamilies with other public and privatecommunity services that are importantfor the overall health of the child andfamily and encourage partnerships withreferral networks to access these re-sources for their patients. Home visitationinformed by mental health consultation

can be an important piece of the medi-cal home model for delivering primarycare that is continuous, comprehensive,family-centered, coordinated, compas-sionate, and culturally effective to allchildren and youth, regardless of theirhealth needs.

Project LAUNCH, which has been aspringboard for innovation in the in-tegration of mental health consultationin home visiting programs as well asin primary care settings, may be apromising platform for future research.Studies are needed on partnership ap-proaches between pediatric practicesandhomevisitingprograms that includemental health consultation and theeffects of these partnerships on theprevalence of maternal depression andthe healthy development of young chil-dren. The epidemic of mental healthconcerns in the nation makes it imper-ative that we determine service modelsthat can be effective with the most vul-nerable families in our communities.

ACKNOWLEDGMENTSWe acknowledge SAMHSA, which pro-vides funding for the Project LAUNCHprogram and the Training and Techni-

cal Assistance Contract led by the Ed-ucation Development Center, and theOffice of Planning, Research and Eval-uation within the Administration forChildrenand Families, which overseesthe cross-site evaluation of ProjectLAUNCH, led by Abt Associates. Wethank Jennifer Oppenheim, ProjectLAUNCHCoordinatorat SAMHSA, LauraHoard, Social Science Research Ana-lyst at the Administration for Chil-dren and Families, and Deborah KleinWalker, VicePresidentatAbtAssociates,for reviewing an early draft of this arti-cle. We also thank the 8 Project LAUNCHgrantees highlighted in the article andtheir local evaluators for providing in-formation about their home visitingprograms that integrate mental healthconsultation. Specific acknowledgmentgoes to the evaluators, local projectstaff, and technical assistance special-ist for the East Oakland, CA, ProjectLAUNCH site: Lisa Erickson, Jill Shinkle,and Gabriel Fain; and the project di-rector and local evaluator for theMilwaukee, WI, Project LAUNCH site:Leah Jepson and Courtenay Kessler. Fi-nally, we acknowledge Missy Robinsonfor her production assistance.

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DOI: 10.1542/peds.2013-1021S2013;132;S180Pediatrics 

Margaret K. GwaltneyBarbara Dillon Goodson, Mary Mackrain, Deborah F. Perry, Kevin O'Brien and

Enhancing Home Visiting With Mental Health Consultation

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Margaret K. GwaltneyBarbara Dillon Goodson, Mary Mackrain, Deborah F. Perry, Kevin O'Brien and

Enhancing Home Visiting With Mental Health Consultation

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