When mothers of young children struggle with feelings of depression, it’s often difficult for them to seek the mental health care they need for themselves. Fear and stigma are significant roadblocks. However, there’s an important, if not-so-obvious person to whom a mother with a young child can turn for help: her child’s pediatrician.
Pediatric care is the most universally accessed system we have for mothers and children. Pediatricians who care for children in families with low incomes—where maternal depression is most likely—have a particularly significant role to play. But, confusion about the role of Medicaid in screening mothers for depression, and treating them, has been another barrier to care.
Now, there’s more clarity about Medicaid policy. On May 11, 2016 the Center for Medicaid and CHIP Services (CMCS) issued an Informational Bulletin explaining how states can support the efforts of pediatric providers so that the serious problem of maternal depression can be addressed.
Pediatricians who currently incorporate screening and treatment for maternal depression into the care they provide to their patients know that helping a mother address the symptoms she’s experiencing directly benefits her child. Strengthening the mother-child relationship sets the child on the path to healthy development.
At Montefiore Medical Center’s Healthy Steps program, that’s what’s happening. Healthy Steps is a program that embeds a child development professional—called the Healthy Steps Specialist—into pediatric care. Specialists help build connections between health care professionals and parents to best address the physical, emotional, and intellectual growth and development of the youngest children. Julia is just one mother who found help for herself and her baby, Michael, (names have been changed to protect privacy) at Healthy Steps. We’ll share their story, but first, some background.
Maternal Depression Can Have Enduring, Damaging Effects
From life’s earliest moments, the relationship between mother and child has a profound effect on a child’s development. A mother’s health, particularly her mental health, is intimately connected to her child’s well-being. A mother suffering from severe depression may be hard-pressed to adequately care for and support her baby. She is less likely to talk and sing to her child, activities central to brain development and social-emotional health.
This is important because words heard from a primary caregiver are the single strongest driver of the size of a child’s vocabulary. By 18 months, there is a significant difference in a child’s vocabulary size, based on family income, education, and maternal depression. Children raised by clinically depressed mothers may perform lower on cognitive, emotional, and behavior assessments than do children of non-depressed caregivers, and they are at risk for later mental health problems, social adjustment problems, and difficulties in school.
As maternal depression can have an enduring, damaging impact on a child, it is critically important to identify and treat depression in mothers of young children as early as possible.
A Two-Generation Approach To A Two-Generation Problem
Pediatricians are in a good position to help reduce the obstacles mothers face when they may be depressed. Taking a child for routine check-ups is not only acceptable and carries no stigma, it is expected. And, since even healthy children are likely to come in for a check-up at least 13 times in the first three years of life, pediatricians may be the only professionals with such consistent connections to their young patients and their mothers — the all-important two-generation “dyad.”
A clinical statement issued by the American Academy of Pediatrics (AAP) considers screening a mother for depression a best practice for primary care providers who care for infants and their families. And, according to Harvard University’s Center on the Developing Child, “treatments designed to improve child well-being must attend to both relieving the mother’s depression and focusing on her interactions with the child.”
The Healthy Steps program at Montefiore Medical Center in the Bronx is implementing this best practice every day. There, pediatricians screen all mothers for depression at their child’s two-month and 24-month visits, using the Patient Health Questionnaire (PHQ-2) screening tool.
When one mother, Julia, brought her two-month old son, Michael, to the pediatrician’s office, the pediatrician administered the PHQ-2 screening questions. When Julia’s responses suggested she might be at risk for depression, the pediatrician got Julia’s permission and then walked down the hall to find Lana, the Healthy Steps specialist. The pediatrician’s “warm hand-off”—a personal, welcoming introduction that increases the chances that mothers will accept behavioral health services—put Julia at ease and was the start of a trusting relationship with Lana, in which she talked about wanting to be the best mother she could be, but feeling overwhelmed by the realities of first-time parenthood.
During weekly appointments, Julia learned techniques to conquer her debilitating symptoms. At the same time, the Healthy Steps specialist worked with Julia and Michael together, and as a result, Julia became more active with the baby and more attuned to his needs and her own. Being able to find care through Michael’s pediatrician meant that Julia could begin treatment with a trusted provider quickly and conveniently, reducing the risk that her symptoms would continue to go untreated, which could have taken a significant personal and economic toll on Julia and her family.
Medicaid Weighs In
If pediatricians have an important role to play, given the data on low-income mothers and maternal depression, so does the Medicaid program. Mothers with low incomes are more likely to experience some form of depression than other mothers. For low-income women, rates of depressive symptoms are reported to be between 40-60 percent, as compared with all pregnant, postpartum, and parenting women, for whom depression affects 5 to 25 percent. It is estimated that more than half of all infants living in poverty are being raised by mothers with some form of depression.
Unfortunately, making a connection at her child’s pediatrician’s office is not as common for low-income mothers as it could be. A host of practical questions around Medicaid policy has presented a significant barrier to maternal depression screening and the delivery of dyadic care:
- When the child is the patient, how does Medicaid view a screening administered to the mother?
- Can maternal depression screening be part of the child’s benefit package under the Early and Periodic Screening, Diagnostic, and Treatment Program (EPSDT)?
- How can a pediatrician help a mother who is found to have depressive symptoms?
- Can treatment include a mother who is not a Medicaid beneficiary herself?
- How can screening and treatment services be reimbursed?
The new CMCS Informational Bulletin helps to clarify the answers to these questions and more. According to the bulletin, state Medicaid agencies may cover maternal depression screening as part of a well-child visit, and a maternal depression screening can be considered an integral part of a risk assessment for the child. Further, since the maternal depression screening is for the direct benefit of the child, state Medicaid agencies may allow such screenings to be claimed as a service for the child as part of the EPSDT benefit.
As with all EPSDT screenings, if a problem is identified, states have an obligation to arrange for medically necessary diagnostic and treatment services to address the child’s needs. These services must actively involve the child and be directly related to the needs of the child. Treatment must be delivered to the child and mother together, but can be claimed as a direct service for the child. A mother who is not Medicaid-eligible can participate in the dyadic treatment with her child.
If treatment is needed solely for the mother, Medicaid can cover services for her if she is enrolled in Medicaid. In the past, many pregnant women with Medicaid lost their coverage 60 days post-partum because their incomes had to be very low for coverage to continue — that income limit was just 42 percent of the federal poverty level, or $8,437 per year for a family of three in 2015 in the median non-expansion state.
Today, with Medicaid expansions in 32 states, including the District of Columbia, where adults can be covered if their incomes are up to 138 percent of the federal poverty level, or $27,724 per year for a family of three in 2015, there is a greater chance than ever before that mothers can qualify. Providers can help mothers apply if they are not already enrolled. For mothers not eligible for Medicaid, there may be community resources to which she can be referred.
In a number of states—including Colorado, Illinois, North Dakota, and Virginia—pediatricians are already performing maternal depression screenings at well-child visits and they are billing the child’s Medicaid. And, in North Carolina, the child’s Medicaid covers 16 unmanaged mental health visits, including visits for dyadic therapy, for mother and child. Providers may include primary care providers, licensed clinical social workers, psychiatrists, and psychologists.
The CMCS bulletin also makes clear that activities designed to promote maternal depression screening and treatment as part of the EPSDT well-child visit are generally eligible for Medicaid administrative matching funds.
What Can The Bulletin Mean For Mothers And Babies?
When Julia reflected upon her experience, she remembered that initially she had strongly resisted the idea of treatment. “My family believes only crazy people go to psychiatrists,” she said. Because of this perception, Julia said she was much more comfortable coming to the pediatrician’s office, where she could walk in, and everyone would assume she was there for Michael. “Come to think of it though,” Julia said as her therapy was coming to a successful close, “I was coming for Michael!”
According to Dr. Pamela C. High, Director of Developmental-Behavioral Pediatrics at Hasbro Children’s/Rhode Island Hospital, “the new screening guidance acknowledges what pediatric providers already know: treating young children within the context of their family is the best treatment model.” Now, with clarity on coverage and billing, expert panels formulating guidance for excellence in health maintenance for young children will be able to include this element in their framework. “That’s a breakthrough,” she said.
States that respond to the CMCS bulletin by adjusting their procedures for covering allowable screening and treatment will be giving providers the tools they need to tackle this serious problem from a two-generation perspective. They’ll be better equipped to provide direct benefits to children covered under Medicaid and will also be helping mothers address their own needs so they can be better, more nurturing mothers.