For mother and child at risk, care that includes a psychologist
By Laurie Tarkan
February 16, 2009 / International Herald Tribune
When she became pregnant, her grandmother offered to buy her a car if she would have an abortion. Other relatives told her the baby would not live to see its first birthday. She was 22, unmarried and had already been hospitalized several times for suicide attempts.
She gave birth to a boy, and when he was 1 week old, the young woman, who spoke on the condition that she not be named, brought him to a pediatric practice at the Children's Hospital at Montefiore Medical Center in the Bronx for a checkup. A doctor recommended that she join an infant-parent psychotherapy group; instead she agreed to home visits.
In the presence of a psychologist, the young woman wondered aloud if she was sexually arousing the baby when she changed his diaper; said the newborn was "demanding," "mean" and "hates men"; and eventually revealed that she had been sexually abused as a girl.
"She was mistrusting and so overwhelmed, and needed much more help," said Rahil Briggs, the hospital psychologist who worked with the young woman at her home. After three months of home visits, Dr. Briggs persuaded the mother to join group therapy twice a week.
"Without this bridge, and me having the flexibility to go to her home and have her gain my trust, she never would have come to the group," the psychologist said. "And if she hadn't, with her set of risk factors, who knows what would have happened to her son? He is securely attached to her, and in my opinion it's fairly close to a miracle."
The group is part of a new effort by the Children's Hospital to protect young children from psychological damage that can be common in poor families.
Experts say Montefiore's new program is a rare example of mental health services for children under 5, a population that Evelyn Blanck, co-president of the New York Zero to Three Network, described as "under the radar screen." Many pediatricians are not trained to recognize psychological problems, and surveys show that parents often complain about physicians' lack of support for behavioral issues.
"There is really a disconnect between the genuine needs and challenges that are facing our young children and their families and what doctors are providing," said Dr. Dina Lieser, executive director of Docs for Tots, a nonprofit group that advocates for young children.
The National Academy of Sciences released a report on Friday calling on federal, state and local governments to make prevention of mental, emotional and behavioral disorders in young people "a very high priority." The report called the current emphasis on treatment once mental disorders emerge as "myopic," and said that prevention means focusing on people with early symptoms and risks, such as maternal depression or poverty.
At Montefiore's pediatric practice, the Comprehensive Family Care Center, there is a psychologist on site, and doctors — who are trained to recognize depression in parents — screen each patient for mental health concerns. Of 2,400 children screened since 2005, 1,120 have been recommended for mental health services, and 780 have participated.
The screening program currently costs the city $20,000 to $30,000 a year; therapy is generally covered by Medicaid. The Altman Foundation has covered the $150,000 yearly cost for a separate program, known as Healthy Steps, which since 2006 has screened 250 families at the family care center and provided individual and group counseling.
In Healthy Steps at Montefiore, which is part of a national program, 20 percent of the mothers are teenagers, 27 percent grew up in foster care, 37 percent have parents with mental illness, and more than 10 percent were physically or sexually abused — all risk factors for their babies' healthy mental and social development, according to Briggs. Research shows that environmental factors like poverty, homelessness, domestic violence and drugs can lead to depression, anxiety, aggression, poor academic performance, autistic behavior and social or developmental delays.
"If a child is exposed to chronic or toxic stress, his reaction to stress gets turned on way too quickly," Briggs said, citing one case in which the mother of a 2-year-old boy wondered whether it would be normal for his tantrums to have intensified after he witnessed the fatal shooting of his father on the street.
According to doctors at Montefiore, a child enrolled in the Healthy Steps program is one-third as likely to score "at risk" for social or emotional developmental problems. Among mothers in the program, depression dropped from 30 percent at the first visit to 6 percent after two months, while 35 percent reported feeling unsupported at the first visit compared with 10 percent at two months.
One recent morning at the hospital's family care center, a half-dozen mothers sat in a circle as their babies and toddlers played with bubbles on a foldout mat. It seemed like a typical mommy-and-me group, with talk of breastfeeding and gassy babies. But in this group, which was run by a social worker, some of the problems preceded the births: Erika Hernandez, 30, said she had been abused by her stepfather and spent most of her pregnancy homeless; Amanda Agosto, 32, said she had been frequently abandoned by her mother, who she said has bipolar disorder and schizophrenia; others were single and poor.
Though cost is often cited as a reason for not providing mental health services to children, Dr. Andrew Racine, director of general pediatrics at the Children's Hospital at Montefiore, said the costs to society only rise if problems are ignored.
"We are seeing the enormous payoffs when you intervene with a child at six or nine months," said Racine. "But the ability to intervene or change the trajectory narrows as the kids get older. By the time you get to school-aged children, it already costs a lot more money, time and energy for less returns."
As an example, Briggs cited Emily Caraballo, 22, and her son, Hector, who before age 4, she said, had witnessed his father physically and verbally abuse his mother. Before an appointment last fall, Briggs was summoned by a security guard to the waiting room, where she found Caraballo "bleeding all over her face because her son has scratched her, and she has him pinned down on the floor so he doesn't hurt anyone."
"Hector had never received a single ounce of help of any kind — he's never even been in a school setting because he's out of control," Briggs said. "This is a kid who should have been seeing me since the time he was an infant and this would have been a different story."
Caraballo now lives in a domestic violence shelter, and her son is at one of the city's two psychiatric hospitals that take children under 5. "They say to be a better parent, you need to be strict," she said. "But Briggs took the time not only evaluate him, but to look at the circumstances that cause the situation. He developed a rapport with Briggs, he feels comfortable speaking about what he's witnessed between me and his father."