Intervention Design
MA_LAUNCH was conducted in Boston, Massachusetts and was designed to address needs of children at risk for social, emotional and behavioral problems by providing behavioral health services and case coordination within pediatric medical homes. The model (Boston Public Health Commission
2014) included the role of the “family partner,” as described above and below, to work collaboratively with a clinician who had masters-level training in mental health care for very young children. While the family partner role resembles that of other community health workers, it is distinguished in this model by the requirement that family partners have lived experience raising a child with a history of social, emotional or behavioral difficulties. The family partners were able to engage with families differently than the clinicians by drawing on shared experiences, modeling effective strategies for parenting, and advocating on behalf of their children. Both team members were employed by the health care site using funds from the grant and participated in ongoing trainings run jointly by the local and State public health departments on evidence-based early childhood development, mental health, and parenting interventions. At least one MA_LAUNCH team member at each site was multi-lingual in languages relevant to populations served. In addition to trainings, MA_LAUNCH teams benefitted from biannual cross-site/cross-project learning collaboratives and monthly meetings with medical and behavioral health staff from each site and the MA_LAUNCH team (Oppenheim et al.
2016). Clinical consultation, technical assistance and administrative supervision was provided by the local public health team throughout to assist in integration of MA_LAUNCH services into each center and in keeping fidelity to the model.
Massachusetts pediatric practices receiving MassHealth (Medicaid) reimbursement, including the three MA_LAUNCH sites, are required to implement behavioral screenings at each well-child visit. Based on screening results, clinician judgement or family concerns, warm handoffs were made to the MA_LAUNCH teams during the intervention period, who introduced families to the program and enrolled them if appropriate. Subsequent steps in the service delivery process were (1) completion of intake and informed consent processes, (2) administration of social and mental health needs assessments; (3) collaborative development of a care plan based on child needs and family priorities; (4) initiation of case management and related referrals; and, as needed, (5) child mental health and/or parenting interventions.
Multiple child and family factors were explored in clinical assessments—socioeconomic, relational, immigration, perinatal, traumatic, developmental, cultural, and more—and became important aspects of the team’s formulation and guiding framework for care plans. The in-depth clinical assessment included consultation with the primary care provider, objective screening tools, caregiver interviews gathering family history, observations of the child and family when possible, and play-based interaction when indicated; interventions were then tailored to the family’s unique needs. For example, a concern regarding a child’s behavior at childcare or preschool could stem from a variety of factors; after careful clinical assessment and formulation, such a concern might be addressed through a combination of developmental psychoeducation and guidance for the caregiver, observations at the school and/or consultation with the teacher, and follow-up as needed to provide the caregiver and/or teacher with recommendations. In multiple cases, support included helping the caregiver to better define and voice concerns with the school or daycare while simultaneously supporting the relationship between caregiver and school/teacher. This support often, in turn, strengthened the relationship with and availability of the school/teacher toward the child and became important to ameliorating the issue.
When adjustment was a concern, whether due to a new sibling, new schools, immigration, a separation or loss, or other cause, the team worked with the family, pairing play-based, dyadic intervention with caregiver guidance. Additionally, interventions often incorporated supporting the caregiver’s reflective functioning related to the child’s subjective experience, emotions, and responses, also known as parental mentalization. Parental mentalization is thought to not only support the child’s experience, regulation, and social emotional development, but to also support the caregiver’s own regulation and subjective experience as a parent in the face of challenges (Sharp and Fonagy
2008). Another significant opportunity presenting in primary care is seeing caregiver(s) during the perinatal period. Perinatal depression and emotional dysregulation represent the most common complications in the perinatal period and have impacts on the caregiver, baby, and family system (Meltzer-Brody
2011). Often complicated by additional stressors such as income loss and housing, perinatal mental health concerns were commonly referred to MA_LAUNCH teams by primary care providers and supporting families during this critical time became an area of focus. When child or family challenges necessitated interventions beyond the scope of MA_LAUNCH, the teams made referrals to in-house or external referral sources, but typically continued to be part of the family’s longer-term supportive pediatric care.
Trainings built into MA_LAUNCH benefited whole centers. For example, in one health center, 25 health center staff from diverse disciplines and roles—including primary care physicians, nurses, medical assistants, social workers, and interpreters—engaged in a two-day MA_LAUNCH-funded training on supporting budding relationships between caregivers and their newborns, and the caregiver’s own subjective sense of competency in their new role. In addition to these patient- and provider-specific activities, MA_LAUNCH teams developed activities within the medical home setting to engage and educate MA_LAUNCH families and overall pediatric clientele. Activities led by the family partners and clinicians from MA_LAUNCH were family-centered and encompassed both health promotion and prevention activities to engage whole families, including health center-wide events such as family game nights, kindergarten registration workshops, caregiver support groups, playgroups, and field trips.
For the evaluation study, assessment, screening and service data were entered by site teams into databases created by the evaluators. After families gave consent, these project records were transferred to the evaluators for analyses. Four Institutional Review Boards (IRB) reviewed and approved all procedures and protocols of the evaluation study: Northeastern University, MA Department of Public Health, Boston University and one participating site’s IRB.
Measures
Two parent-report screening tools were used to assess social emotional and behavioral concerns of children, with improvement defined as participant movement from clinically concerning ranges into healthy ranges. The Ages & Stages Social and Emotional questionnaire (ASQ-SE) was used with children age 5 and younger and the Child Behavior Checklist (CBCL) with children 6–8 years. For children who began the study at age 5 and ended at age 6, they were screened with the ASQ-SE first and the CBCL later. The ASQ-SE is a screening and monitoring tool to identify social emotional problems in children 0–6-years-old, with 19–30 items and good internal consistency (α = 0.82) and test–retest reliability (0.94) (Squires et al.
2001). Clinical cutoff scores for each age group indicate follow-up and monitoring needs (Squires et al.
2002). The CBCL contains 120 items assessing emotional or behavioral problems in the past 6 months, with scores above 63 considered clinically concerning; strong reliability and validity has been demonstrated in many populations (Achenbach and Rescorla
2008; Nakamura et al.
2008).
Two tools were used to measure caregiver functioning: the Patient Health Questionnaire-9 (PHQ-9) and the Parenting Stress Index-Short Form (3rd Edition) (PSI-SF). The PHQ-9 is a self-administered, nine-item depressive symptom subscale of the full PHQ based on DSM-IV diagnostic criteria, with demonstrated validity as a screening tool with diverse primary care patients, strong internal (α = 0.86–0.92) and test–retest (0.83–0.84) reliability (Huang et al.
2006), and 88% sensitivity/specificity for depression diagnoses (Kroenke et al.
2010). Each item is scored from 0 (not at all) to 3 (nearly every day) and summed to obtain scores from 0 to 27, with ≥10 representing clinically significant depressive symptoms. The PSI-SF is a 36-item abbreviated version of a 120-item scale used widely to measure overall parental stress (Abidin
1995). Scores from 16 to 84th percentiles are considered within the normal range while 85th percentile indicates clinically significant stress (Reitman et al.
2002).