Wayne State’s early childhood clinic has pediatrics and mental health
Sometimes Carolyn Dayton will talk with new moms who say they are doing just fine. But ask them if they’re getting any sleep, how they’re feeling — slow down and say you understand how hard it is to have a 3-month-old — and then the tears come.
“Now I can intervene,” said Dayton, associate director of a year-old Wayne State University program aimed at identifying new parents who need mental health support and getting behavioral health services both to them and their young children. “Now I can provide whatever services might be available.”
Wayne State’s Infant Mental Health Program at the Merrill Palmer Skillman Institute for Child & Family Development deftly screens parents in person during routine well-child visits to assess their basic needs, mental health and overall well-being. Then it offers support for issues from housing insecurity to perinatal mood and anxiety disorders, which affect up to 20% of postpartum women.
Currently grant-funded by two foundations through May 2025, clinic leaders are advocating for state support as well as Medicaid policy changes that would allow for reimbursement of adult mental health services provided in the pediatric setting — something that hasn’t been done before in Michigan. Medicaid changes were allowed in California, and Michigan can look to other models, but making such programs sustainable has been rare and difficult.
Making their early childhood support clinic a “one-stop shop” for physical and mental health lowers the barriers of transportation, awareness and stigma when it comes to new moms and dads getting help for problems that are too often overlooked — and that affect children’s mental and physical health.
“Mental health is huge,” Dayton said. “We need to address it if we’re serious about addressing infant and maternal morbidity and mortality.”
Babies’ and parents’ health are intertwined
For children to develop in healthy ways, their parents must be relatively healthy, and their environment must be healthy, according to Sheryl Kubiak, dean of the Wayne State University School of Social Work and founding director of the Center for Behavioral Health and Justice. “And so, when children are young, there has to be a dual focus on both the child and the parent,” she said.
But that’s not usually the case. After 40 weeks of intense interest in her physical well-being, a new mother often feels jettisoned postpartum, as clinicians focus on her infant.
After delivering a baby, a child typically has around 10 visits over the next 18 months. The mother has one visit, six weeks postpartum. Many don’t even show up for the appointment; many are back at work by then, picking up shifts, taking care of other kids or stuck without reliable transportation.
“Infants are clearly rapidly developing little bio-organisms that are very dependent on interaction with a caring, loving adult,” said Dr. Herman Gray, chair of Wayne State’s Department of Pediatrics. “If you do not have the dynamic of capable, caring, loving adults in the lives of infants, they’re not going to do well. … They’re not going to thrive.”
A mom who is too depressed to get out of bed may forget to feed her child. Relationship problems between parents and young children seep into preschool, where little kids get in trouble for exhibiting behaviors that took root in a stressful home.
Moms in mental distress are less likely to take great care of a newborn or go to the doctor themselves and are more likely to abuse substances or contemplate self-harm.
Deaths from suicide, drug overdoses and other mental health and substance use issues are the leading cause of pregnancy-related deaths in the U.S.
And evidence shows more parents are likely struggling with perinatal mood and anxiety disorders: One study revealed that between 2008 and 2020, the rates of privately insured people diagnosed with such conditions increased by more than 93%. Black individuals had the largest increase, according to study author Dr. Kara Zivin.
This was due, in part, to clinical guidelines issued in 2015 to universally screen for depression during and after pregnancy. But those screeners don’t catch everyone, and getting diagnosed doesn’t automatically equate to getting effective treatment. Up until May 2015, only 30% of people with postpartum depression are identified, just 15% receive treatment, and less than 5% achieved remission.
“Integrating screening for maternal mental health into pediatric care is feasible and can lead to better outcomes for women, which can lead to better outcomes for infants,” Zivin said.
‘We’ve got to make this easier for families’
In the conventional model, new parents bring their infants in for a plethora of pediatric visits, while navigating the brave new world of parenting mostly alone.
Their expectations are often misaligned with reality: They’ve brought home what Gray called “a little screamy-meemie that only sleeps every 15 minutes, it feels like, and (is) highly demanding, selfish and pooping all the time.”
Asking new parents, already stressed and overwhelmed, to make separate appointments in disparate locations can cause things to fall through the cracks. Throw in a lack of providers and long waitlists and the problem is compounded.
When Priority Health looked at its pregnant patients on Medicaid in southeast Michigan, it found 40% of them had a mental health concern.
“A mom doesn’t have time to take care of herself and to care for babies,” said Shannon Wilson, executive director of the Priority Health Total Health Foundation, which contributed $100,000 to the clinic. “So we’ve got to make this easier for families.”
Making it easy for new parents to get mental health support makes the healthy choice the default choice, according to Wilson. No bus ride, no babysitter, no list of numbers to call.
“It’s not a new concept in the world of medicine,” Gray said. “But increasingly, particularly with the emphasis on social determinants of health (and) health disparities — which our department and I are very interested in doing a better job addressing — having mental health services on-site, present, in real time, when you’re also delivering pediatric care is just, I think, essential to meeting the needs of your patients and their families.”
Helping parents and kids along a spectrum
Plenty of parents who bring their children into the early childhood support clinic are doing great. Many times, it becomes clear through not just a quick questionnaire but a conversation with staff that a parent could use a little help.
Maybe they’re not getting sleep and they’re concerned about how fussy the baby is. These parents might just need a little support — some validation, a few suggestions, perhaps a follow-up call to see whether they’ve managed to test that new baby hold and whether it helped.
That was mostly what Eboni Pullins needed: some encouraging words as she made the transition from one child to two and dealt with some rough behavior from a toddler who was adjusting to having a new baby sister.
“I think it’s really important, with all that we know about postpartum concerns with moms in general,” Pullins said during an appointment at the clinic, where she couldn’t help but coo and smile at 4-month-old Olivia, who had just awakened. “It can be rough. And to have that support and mindfulness — it definitely helps.”
Other moms need help getting their basic needs met; they’re worried about unstable housing, a lack of food, child care needs for older kids.
At the far end of the spectrum are the parents who have severe mental illnesses, from postpartum depression or anxiety to psychosis. They need to be linked with psychiatric services and may need medication.
“Sometimes people are putting their own mental health needs on the back burner,” Weathington said, especially if they’re concerned about basic needs. “It normalizes how important the parents’ health is.”
Based on needs, rooted in relationships
Michigan clinicians have long recognized that sometimes medicine needs to come to the patient and not the other way around. The “Michigan model” of infant mental health, pioneered in the early 1970s, brought master’s level providers into the homes of at-risk parents and young children with weekly relationship-focused interventions that helped stave off serious mental health issues.
“Mental health home-based services are fantastic, they’ve helped a lot of families,” said Dayton. “But it’s not getting to lots of the families who need it.”
Wayne State’s early childhood support model allows clinicians to observe the relationships between parent and child and offer relationship-based solutions to relationship-based problems.
And it allows mental health problems to be identified and treated as soon as they arise — a more preventive model that its funders believe is the best approach for all health.
“That’s how we feel about mental health,” said Andrea Cole, president and CEO of the Ethel and James Flinn Foundation, which provided $150,000 to the clinic over two years. “You should be getting to people in primary care settings, you should be diagnosing them early when it’s much more manageable, so that it doesn’t escalate to a chronic illness.”
Catching adults while they’re at an appointment for their child also removes the barrier of shame and stigma with which mental health care is still shaded. Parents might not want to show up to a mental health visit, but 90% of families visit the pediatric office.
“People still do worry, ‘What are people going to think of me if I have a mental health condition while I’m pregnant, I have a baby?’ ” Zivin said. “ ‘Do I bring it up? What’s going to happen to me or my child?’ “
Especially among communities disproportionately investigated by the child welfare system, sounding the alarm about mental health distress, food insecurity or substance use — even admitting to having questions and concerns about caring for young children — can feel like dangerous confessions, even in the doctor’s office.
“There’s a lot of history of using these sorts of things against Black mothers,” said Dr. Yamicia Connor, an OB-GYN with a focus on minority health policy who also founded two minority health-focused organizations. “So, if you do report that you’re feeling really depressed or feeling really anxious, how is the health system going to deal with that? Are they going to call social services? If you have an addiction disorder, is that going to put your life in chaos?”
And although the stigma against getting help plays out in tangible ways, Connor said it’s also a symptom of living in a society that doesn’t always give help to those who ask for it — specifically Black women.
Rather than simply asking pregnant or postpartum women to self-identify, Connor said the approach must be based on trust, and relationships — both for the individual and the community.
“If that work isn’t done up front, I don’t know if it’s going to be effective for the majority of women,” she said.
More:Pilot projects will help stop the overreporting of children of color to child welfare
More:A federal law demands mental health care parity. Why don’t kids in Michigan get it?
Training the next generation of practitioners
Despite the prevalence of perinatal mood and anxiety disorders, few clinicians are formally trained to identify and address them.
Connor said every physician does a psychiatry rotation, but most of it is focused on inpatient care — not where most people receive psychiatric services. Despite training at some of the most prestigious institutions in the country, Connor couldn’t remember any formalized rotations specific to mood disorders in medical school or residency.
“Given that it’s one of the highest causes of maternal mortality, that’s really shocking,” she said.
At the early childhood support clinic, students in Wayne State’s infant mental health training program get a chance to see how bringing practices together can make caring for babies and parents more effective and more efficient.
“That’s training that you don’t get in the classroom,” said Kubiak, the Wayne State social work dean. “It has to be in the practice environment. And so, we really do recognize and appreciate our opportunity to train the next generation of practitioners to do integrated care.”
“In most pediatric clinic settings, if you have those professional cues that things may not be going all that well, your option is to tread into territory that you’re not necessarily particularly trained or skilled at, or to make a referral,” said Gray. At Wayne State’s early childhood support clinic, trained social workers, including Beverly Weathington, are right down the hallway to pop in on a new mom and evaluate her needs.
Katarina Kolobaric, who is pursuing her master’s degree in social work at Wayne State’s Merrill Palmer Skillman Institute, has appreciated the opportunity to see infant mental health translated into an integrative health setting — and to witness the fortitude of the families she has met with at the clinic.
“It’s really profound to see how resilient families are,” Kolobaric said. “To have that opportunity to provide them whatever support I’m able to provide them is really humbling to be part of their experience in that way.”
Can grants sustain the clinic until policy changes?
Integrated health care has proven to be successful for patients. In eight months, Wayne’s early childhood support clinic has served nearly 250 families, according to Alissa Huth-Bocks, director of the Merrill Palmer Skillman Institute.
In that time, it has become clear this clinic is meeting a huge unmet need. “We are collecting data on what we’re addressing, and almost everything we’re addressing would have been missed,” said Huth-Bocks. “We are addressing needs that would go unaddressed. Unaddressed. And they’re serious.”
The top concerns for families who used the clinic included help with basic needs like formula, car seats, diapers, food and housing, concerns about developmental delays and caregiver mental health.
The real question is, can it last?
No matter how seamless or effective the care is, it cannot be sustained until someone figures out how to pay for it. And under Michigan’s current Medicaid policy, staff can’t bill for an adult visit in a pediatric clinic. Around 80% of the early childhood support clinic’s patient population is insured through Medicaid.
“There are places that actually do justify billing under the child’s name … to do an intervention with the parent, because it is in the service of the child’s health,” said Huth-Bocks. “But this idea is foreign to even most pediatricians.” Same for local hospital administrators, medical coding specialists and state Medicaid offices.
Some clinics have figured this out. A national, evidence-based model of birth-to-3 integrated pediatric care called Healthy Steps is active at more than 260 sites in 25 states, though not Michigan. Its interventions have shown an average annual Medicaid return on investment of 163%.
California successfully advocated to get new procedural codes added to Medicaid so that providers could be reimbursed for treating a child-parent pair. Cincinnati Children’s Hospital figured out a sustainable billing model to deliver this kind of relationship-based integrated care to families.
But this work can be slow. It took Cincinnati Children’s eight years to get to a point of financial sustainability. So while Wayne State has a model to look to, it may have to get creative as it works to build its own solution. “We might be the demonstration project in Michigan to build this out,” said Huth-Bocks.
Even if Medicaid would reimburse for adult mental health care provided in the pediatric space, its reimbursement rates can be dismal and funding gaps would need to be filled — with the hospital’s own operating budget, by clinicians providing other services that bring in higher revenues or with ongoing philanthropic support.
“I think we would all like there to be higher-level policy worked on where we would actually get reimbursed at a rate that allows us to do this full time, because the patient need is there,” Huth-Bocks said. “It’s very great.”
Private grants are doing the heavy lifting for now, and the clinic continues to apply for more funders to partner in what Huth-Bocks called “transformative care with a big return on investment.” They’ll enable the clinic to run while it generates the base of evidence to prove it should be funded long-term, by an entity such as the Michigan Department of Health and Human Services, through Medicaid reimbursement or some combination of sources.
“Oftentimes, foundations have to get in and fund things so that we can prove the concept, and then once the concept is proven, everyone else will get on board,” said Wilson. “So, we’re really trying to drive where we think the future will be.”
Jennifer Brookland covers child welfare for the Detroit Free Press in partnership with Report for America. Make a tax-deductible contribution to support her work at bit.ly/freepRFA. Reach her at [email protected]. Submit a letter to the editor at freep.com/letters.
This article was reported through a fellowship supported by the Lilly Endowment and administered by the Chronicle of Philanthropy to expand coverage of philanthropy and nonprofits. The Detroit Free Press is solely responsible for all content.
link
