Infant and Early Childhood Mental Health in Pediatric Care

Introduction

Nearly all young children in the United States have regular access to a pediatric primary care provider. In 2019, 97.6 percent of children 0-4 had a usual place of health care[i] and 97.5 percent had a well-child check-up in the past 12 months.[ii] Regular visits with a trusted care provider offer a significant opportunity for families and care providers to identify and address infant-early childhood mental health (IECMH) conditions.[iii] In recognition of the importance of children’s IECMH and the role that pediatric providers can play in its support, the American Academy of Pediatrics (AAP) convened a Task Force on Mental Health (2004–2010) and its successor, the Mental Health Leadership Work Group, which issued Mental Health Competencies for Pediatric Practice in 2019 along with guidance on achieving them. The AAP’s Bright Futures screening guidelines recommend a psychosocial/behavioral assessment be conducted at each of the 15 well-child visits during the child’s first five years.[iv]

Despite these recommendations and guidance, barriers remain to incorporating IECMH supports into pediatric practices, including low levels of screening with standardized tools, a lack of IECMH-related training for pediatric providers, and few relationships with referral sources for IECMH evaluation and treatment.[v] A number of federal policy efforts have aimed to address these and other challenges, including the 21^st Cures Act, which funded grants to support child psychiatry consultation,[vi] and Project LAUNCH, a Substance Abuse and Mental Health Services Administration (SAMHSA) initiative that promoted integration of behavioral health into pediatric primary care settings as one of its five strategies.[vii] Policymakers have also explored opportunities and made recommendations for using Medicaid funds to expand support for IECMH in pediatric settings.[viii]

State Profiles that Include Infant and Early Childhood Mental Health in Pediatric Care

Research Support for Infant and Early Childhood Mental Health in Pediatric Care

This summary explores the research evidence for a range of approaches to support IECMH in pediatric settings identified by researchers, policymakers, and practitioners.[ix] These approaches are IECMH screening and response, delivering IECMH services in pediatric settings, and IECMH consultation. When combined, these approaches can complement and reinforce each other, with training and ongoing professional development for pediatric and other professionals playing a key role in their successful implementation.

This evidence summary focuses on studies conducted in the United States that present findings on the relationship of supports for IECMH in pediatric settings to the social-emotional and behavioral outcomes of children birth to five. Some approaches include links to other PRiSM evidence summaries.

IECMH Screening and Response

Universal screening with standardized tools is critical for identifying risks for IECMH conditions. Screening with an instrument that focuses on early development and behavior in the social-emotional domain (e.g., ASQ-SE) has been found to identify more young children at risk of mental health conditions than the use of a general developmental screener.[x] Screening should also cover other risk factors associated with IECMH challenges, such as maternal depression and other conditions that increase children’s risk of mental health problems, including housing instability, food insecurity, domestic and community violence, and substance abuse. Appropriate responses to positive screens, such as referrals, warm handoffs, and follow-up, are also necessary to ensure the benefits of screening. Because pediatricians typically have limited time to provide supports or case-management that help families connect to and engage with a service to which they are referred, other professionals who work in or with pediatric settings typically provide this support (see PRISM evidence summary on case management). In general, there is evidence that screening and response in pediatric settings leads to positive IECMH outcomes. Other PRiSM evidence summaries that provide related information are: child social-emotional screening and response, maternal depression screening and response, and risk factor screening and response.

IECMH Services in Pediatric Settings

In addition to identifying IECMH needs and facilitating access to services, IECMH interventions and supports may be delivered onsite in pediatric settings, either by a pediatrician or another professional. Most of the models show promise, although several studies have limitations (e.g. lack of random assignment, small samples).

Positive Parenting Program (Triple P) is an evidence-based program that teaches parents of children from birth to age 17 strategies to promote social competence and self-regulation in children. Triple P consists of five tiers, with two universal tiers designed for all parents and three tiers of targeted supports for families with greater needs. Fifty-three pediatric residents were randomly assigned to a control or training on Primary Care Triple P, an adaptation of Triple P consisting of 1 to 4 sessions delivered to parents in a pediatric setting. Residents participated in 12 hours of initial training followed by a half-day accreditation training session 6- to 8-weeks later. Parents of children 18 months to 12 years (mean age 4.8 years) who saw a Triple P resident reported significantly greater improvements in use of positive discipline techniques, though no effects were found on parenting sense of confidence or parent reports of child externalizing behavior problems.[xi]

Promoting First Relationships in Pediatric Primary Care (PFR-PPC), is an adaptation of a home-visiting program, Promoting First Relationships (PFR), that helps pediatricians, nurses, and other health care professionals incorporate support for positive parent-child relationships during well-child visits. The program includes observation-based feedback and parent hand-outs to help parents understand infant-toddler cues and engage in interactions that foster a positive, nurturing relationship. Traditional PFR, delivered as a home-visiting program, has shown positive outcomes for caregivers and children in a number of randomized controlled trials.[xii] While PFR-PPC has not been formally evaluated, a report from the Center for the Study of Social Policy on social-emotional supports in pediatric primary care included findings from case study site visits in pediatric settings implementing PFR-PPC. In these visits, staff reported better relationships with parents, and parents reported that PFR-PPC helped them support their children’s social-emotional development.[xiii] A PRiSM profile examines PFR-PPC implementation in Washington State.

The Brief Behavioral Intervention (BBI) consists of five 50-minute sessions delivered weekly by a clinician to individual families and focuses on parent skills, including identifying problem behavior, child-directed play, and communicating expectations about child behavior. Follow-up sessions focusing on skills a parent finds challenging are available as needed. In a study of BBI in a children’s hospital outpatient clinic, pediatricians and health care providers in other hospital clinics referred 31 parents of two- to 6.5-year-old children with a concern of externalizing behavior problems to BBI. Parent and teacher reports of child behavior problems showed significant improvements from pre- to post-treatment, with parents receiving a mean of 7.2 sessions.[xiv] In a second study of BBI in a children’s hospital outpatient clinic, parents of 120 two- to 6.5-year-old children with clinically significant disruptive behavior were referred to BBI. Parent and teacher reports of child behavior problems showed significant improvements from pre- to post-treatment, which were maintained at six-months and one-year follow-up.[xv]

Child-Adult Relationship Enhancement (CARE) is a trauma-informed group training for caregivers that teaches them to support children’s social-emotional development. Two different adaptations of CARE have been delivered in pediatric settings. The first adaptation, Child-Adult Relationship Enhancement in Primary Care (PriCARE), consists of six 1.5-hour weekly sessions for six to eight caregivers delivered in a primary care clinic by licensed mental health professionals trained on PriCARE. A study of PriCARE that randomly assigned 80 parents of children two to six years old with behavior concerns to PriCARE and 40 to a control group found significantly greater improvements in parent reports of child behavior problems among PriCARE parents at program completion and seven weeks after.[xvi] The second adaptation, IntegratedCARE (I-CARE), was developed for use in integrated behavioral health clinics and is delivered by trained clinical social workers to the parent-child dyad over three 20- to 40-minute sessions in the examination room at the time of the health care visit. A study of I-CARE with 30 parents of children two to eight years old with behavior concerns found significant decreases in parent-reported problem behaviors from pre- to post-intervention.[xvii]

The Incredible Years (IY) series consists of child, parent, and teacher programs that aim to reduce the challenging behaviors and support the social-emotional development of children from birth to age 12. The IY parenting program involves weekly 2-3 hour sessions for groups of 10-14 parents. Recorded vignettes serve as the basis of discussion during the sessions, which are delivered in a number of settings, including community agencies, healthcare settings, and schools. A number of studies have examined IY delivered in pediatric settings. In one study, parents of two- to four-year-old children with disruptive behaviors were randomly assigned to receive a 10-week IY parenting group delivered by a clinician and a member of pediatric staff or to a no-treatment group. Significant positive effects were found for the IY parents on both observed and reported parenting behaviors and child problem behaviors at post-treatment and follow-up at 12 months.[xviii] Another study of 23 parents with two- to three-year-old children with symptoms of attention deficit hyperactivity disorder and oppositional defiant disorder who participated in a 10-week IY parenting program led by a nurse practitioner and doctoral student in clinical psychology found significant improvements in parent-reported child problem behaviors at post-intervention and six months.[xix] A third study randomly assigned 117 parents of three- to six-year-old children with oppositional defiant disorder in 24 pediatric practices to a 12-week IY parenting program led by either a registered nurse or a clinical child psychologist or to a control condition in which parents received an IY book. While there were no significant overall treatment group differences in parent-reported child behavior at post-treatment and 12-month follow-up, IY parents showed significant improvements over the control group on one measure of child behavior if they attended at least seven sessions and on a second measure if they attended at least nine sessions.[xx]

Parent-Child Interaction Therapy (PCIT) is a dyadic treatment model that involves observation and coaching of parent-child interactions and is designed to address externalizing behavior problems for children from two to seven years [see PRiSM research summary on dyadic treatment for more information on PCIT]. Primary Care-PCIT (PC-PCIT) is an abbreviated group preventive intervention delivered in four 1.5-hour sessions to two to four parent-child dyads in primary care by therapist coaches. A study randomly assigned 17 parents of children age three to six years with behavior concerns to PC-PCIT and 13 to PCIT-Anticipatory Guidance (PCIT-AG), in which parents receive written PCIT materials for a self-guided intervention. Significant improvements from pre- to post-intervention and at 6 months post-intervention in parent reported problem behaviors were found for both groups, but the four-session, in-person group intervention was not found to have greater impacts.[xxi]

In a study of Primary Care Triple P (PCTP), two accredited Triple P practitioners sequentially introduced the four-session PCTP intervention to parents of 10 children aged three to seven years old with concerns about behavior problems. From pre- to post-intervention, video-based observational measures showed lower levels of disruptive behavior in situations cited by the family as challenging and in other situations, and parents reported significant improvements in disruptive behavior; outcomes were maintained at four-months follow-up.[xxii]

The Video Interaction Project (VIP), promotes positive interactions between the parent and child at well-child visits beginning in early infancy through age two years. During each visit a child development specialist meets briefly with the parent and child to offer a book or toy and record a short play or reading interaction. The specialist then watches the video, celebrates positive features, helps the parent(s) develop goals, and suggests activities. A study that randomly assigned 52 newborn children at risk of developmental delay to VIP and 47 to a control group found significant positive effects on child cognitive development but not parent-reported behavior problems at 33 months.[xxiii] A second study that randomly assigned 675 newborn children and their parents either to VIP, a group that was mailed information and learning materials, or a control group found significant positive effects for VIP on parent-reported child social-emotional development, including imitation, attention, separation distress, hyperactivity, and externalizing problems, at 14, 24, and 36 months.[xxiv]

IECMH Consultation

IECMH consultation is “a prevention-based service that pairs a mental health consultant with families and adults who work with infants and young children in the different settings where they learn and grow…. The aim is to build adults’ capacity to strengthen and support the healthy social and emotional development of children.”[xxv] (See PRiSM evidence summaries for additional research on IECMH consultation in early care and education (ECE) settings and home visiting.)

One approach to IECMH in pediatric settings is the child psychiatry access program (CPAP), which provides a child psychiatrist-staffed hotline to pediatric primary care providers with concerns about their patients’ mental health. CPAPs may also provide referral assistance, professional development trainings, and in-person evaluations and consultation. A recent research review found CPAPs in 11 states, though only one quantitative study that included outcomes for children under 5.[xxvi] That study, an evaluation of a CPAP in Washington State, examined the fee-for-service Medicaid claims for 158 children (13 percent under 6 years old) from 32 months prior and 12 months after CPAP usage and found significant increases in psychiatric medication use.[xxvii] However, the study did not report whether CPAP specifically increased psychiatric medication for young children, an outcome that is likely harmful to most children in this age group.

Other approaches to IECMH consultation in pediatric settings correspond to those typically seen in ECE settings, with onsite consultation delivered by IECMH specialists and focusing on supporting program-wide aspects and practices in the pediatric setting and/or addressing concerns about particular children. A number of federal Project LAUNCH grantees used funding to establish IECMH consultation in pediatric settings. Rhode Island LAUNCH embedded universal developmental and behavioral screening and mental health consultants in pediatric primary care sites. Mental health clinicians serving as consultants assisted pediatric practices with universal screening implementation and other programmatic issues around IECMH, as well as provided informal consultation, more in-depth assessment, and referrals related to particular cases. While an evaluation of Rhode Island LAUNCH did not examine the relationship of screening and consultation to child social-emotional or IECMH outcomes, it did find that children under five years old were less likely than children five to eight years old to have a parental behavior concern or mental health referral, even when controlling for child behavior based on SE screening tools. These findings suggest the need for the use of these screening tools among young children and efforts to engage parents in cases of positive screens.[xxviii]

Project LAUNCH funding also contributed to the development of an IECMH consultation program for pediatric settings in the Lafayette area of Louisiana. In addition to Lafayette, IECMH consultation is offered in pediatric settings in New Orleans (see PRiSM profile for additional information on the approaches used by these two IECMH consultation programs in Louisiana). In New Orleans, outcomes of IECMH consultation have included changes in providers’ self-reported ability to identify mental health needs, overall increase in use of recommended early childhood clinical skills, including promoting use of screens to identify and track disruptive behavior problems, anxiety, and for trauma and adversity exposure (including maternal depression), and a trend towards identifying mood and anxiety problems.[xxix]

Combined/Multi-Component Approaches

HealthySteps (HS) is a national model that integrates supports for young children’s optimal development, including IECMH, into primary care. HS programs integrate a child development expert, the HealthySteps Specialist (HS Specialist), into the pediatric primary care practice or any clinic where well-child visits are provided. HS provides three tiers of services. Tier 1 is available to all families in the practice and consists of child development and social-emotional/behavior screening, maternal depression and family needs screening, and a family telephone support line to address questions on a variety of topics including child development, parenting, and behavior. The second tier of services, for families with mild concerns, includes HS Specialist consultations with families about child development and behavioral concerns, care coordination, positive parenting guidance, and early learning resources. The third tier of services, for families in need of more intensive services, consists of preventive services, including those in Tiers 1 and 2, as well as regular contact with the family during each well-child visit and at other times, as needed. The HS Specialist also makes referrals to community resources as needed, including to infant and early childhood mental health services, such as evaluation and dyadic treatment, and for maternal depression evaluation and treatment. Researchers found that children who had screened at risk for social-emotional difficulties and received HS services showed significant improvements in subsequent social-emotional screenings compared to children in need of services whose caregivers declined services.[xxx] Researchers also found that HS reduced the gap in risk of social-emotional difficulties between children whose mothers had experienced childhood trauma and those whose mothers had not.[xxxi] A PRiSM profile examines HS implementation in New York State.

In Massachusetts Project LAUNCH, trained early childhood mental health clinicians and family partners (paraprofessionals with lived experience of raising a child with SE or mental health issues) were introduced at three pediatric practices to serve children from birth to age eight. Massachusetts pediatric practices are required to conduct behavioral screenings at well-child visits, and warm handoffs were made to Project LAUNCH teams in cases of positive screens. Project LAUNCH services included “(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.”[xxxii] SE screening scores among 188 children birth to age five enrolled in services showed significant improvements from baseline to 12 months post-enrollment, with children starting above the clinical cutoff score on the screener scoring on average scoring below the cutoff at 12 months.[xxxiii]

Last updated December 2021

References

[i] National Center for Health Statistics. (n. d.) Percentage of having a usual place of health care for children under age 18 years, United States, 2019. National Health Interview Survey. Generated interactively: October 28, 2021, from https://wwwn.cdc.gov/NHISDataQueryTool/SHS_2019_CHILD3/index.html

[ii] National Center for Health Statistics. (n. d.) Percentage of having a well child check-up in the past 12 months for children under age 18 years, United States, 2019. National Health Interview Survey. Generated interactively: October 28, 2021, from https://wwwn.cdc.gov/NHISDataQueryTool/SHS_2019_CHILD3/index.html

[iii] Einhorn Family Charitable Trust, Ariadne Labs, & National Institute for Children’s Health Quality. (n. d.). Promoting young children’s (ages 0-3) socioemotional development in primary care. https://www.nichq.org/sites/default/files/resource-file/Promoting%20Young%20Children%27s%20Socioemotional%20Development%20in%20Primary%20Care%20%282016%29.pdf

[iv] American Academy of Pediatrics. (2021). Recommendations for preventive pediatric health care. https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

[v] Gleason, M. M. (2018). Infant mental health in primary care. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (4th ed., pp. 585-598). Guilford. https://massaimh.org/wp-content/uploads/2020/02/Chapter36PrimaryCare.pdf

[vi] Ibid.

[vii] U.S. Substance Abuse and Mental Health Services Administration, NORC at the University of Chicago, & National Academy for State Health Policy. (2017). The integration of behavioral health into pediatric primary care settings. https://healthysafechildren.org/sites/default/files/The-Integration-of-Behavioral-Health-into-Pediatric-Primary-Care-Settings.pdf

[viii] Cohen Ross, D., Guyer, J., Lam, A., & Toups, M. (2019). Fostering social and emotional health through pediatric primary care: A blueprint for leveraging Medicaid and CHIP to finance change. Center for the Study of Social Policy. https://cssp.org/wp-content/uploads/2019/06/Medicaid-Blueprint.pdf

[ix] Doyle, S., Chavez, S., Cohen, S., & Morrison, S. (2019). Fostering social and emotional health through pediatric primary care: Common threads to transform practice and systems. Center for the Study of Social Policy. https://cssp.org/wp-content/uploads/2019/10/Fostering-Social-Emotional-Health-Full-Report.pdf

Gleason, M. M. (2018). Infant mental health in primary care. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (4th ed., pp. 585-598). Guilford. https://massaimh.org/wp-content/uploads/2020/02/Chapter36PrimaryCare.pdf

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[x] Williams, E., M., Zamora, I., Akinsilo, O., Chen, A. H., & Poulsen, M. K. (2018). Broad developmental screening misses young children with social-emotional needs. Clinical Pediatrics, 57(7), 844-849. https://doi.org/10.1177/0009922817733700

[xi] McCormick, E., Kerns, S. E., McPhillips, H., Wright, J., Christakis, D. A., & Rivara, F. P. (2014). Training pediatric residents to provide parent education: A randomized controlled trial. Academic Pediatrics, 14(4), 353-360. https://doi.org/10.1016/j.acap.2014.03.009

[xii] Oxford, M. (2021). Promoting First Relationships: Summary of research 2021. University of Washington, School of Nursing. https://pfrprogram.org/wp-content/uploads/2021/06/Promoting-First-Relationships-research-summary-May-2021.pdf

[xiii] Doyle, S., Chavez, S., Cohen, S., & Morrison, S. (2019). Fostering social and emotional health through pediatric primary care: Common threads to transform practice and systems. Center for the Study of Social Policy. https://cssp.org/wp-content/uploads/2019/10/Fostering-Social-Emotional-Health-Full-Report.pdf

[xiv] Axelrad, M. E., Garland, B. H., & Love, K. B. (2009). Brief Behavioral Intervention for young children with disruptive behaviors. Journal of Clinical Psychology in Medical Settings, 16(3), 263-269. https://doi.org/10.1007/s10880-009-9166-7

[xv] Axelrad, M. E., Butler, A. M., Dempsey, J., & Chapman, S. G. (2013). Treatment effectiveness of a Brief Behavioral Intervention for preschool disruptive behavior. Journal of Clinical Psychology in Medical Settings, 20(3), 323–332. https://doi.org/10.1007/s10880-013-9359-y

[xvi] Schilling, S., French, B., Berkowitz, S. J., Dougherty, S. L., Scribano, P. V., & Wood, J. N. (2017). Child-Adult Relationship Enhancement in Primary Care (PriCARE): A randomized trial of a parent training for child behavior problems. Academic Pediatrics, 17(1), 53-60. https://doi.org/10.1016/j.acap.2016.06.009

[xvii] Scott, B., Gurwitch, R. H., Messer, E. P., Kelley, L. P., Myers, D. R., & Young, J. K. (2021). Integrated CARE: Adaptation of Child-Adult Relationship Enhancement (CARE) model for use in integrated behavioral pediatric care. Clinical Pediatrics, 60(2), 100-108. https://doi.org/10.1177/0009922820959938

[xviii] Perrin, E. C., Sheldrick, C., McMenamy, J. M., Henson, B. S., & Carter, A. S. (2014). Improving parenting skills for families of young children in pediatric settings: A randomized clinical trial. JAMA Pediatrics, 168(1), 16-24. https://doi.org/10.1001/jamapediatrics.2013.2919

[xix] McMenamy, J., Sheldrick, R. C., & Perrin, E. C. (2011). Early intervention in pediatrics offices for emerging disruptive behavior in toddlers. Journal of Pediatric Health Care, 25(2), 77-86. https://doi.org/10.1016/j.pedhc.2009.08.008

[xx] Lavigne, J. V., Lebailly, S. A., Gouze, K. R., Cicchetti, C., Pochyly, J., Arend, R., Jessup, B. W., & Binns, H. J. (2008). Treating oppositional defiant disorder in primary care: A comparison of three models. Journal of Pediatric Psychology, 33(5), 449-461. https://doi.org/10.1093/jpepsy/jsm074

[xxi] Berkovits, M. D., O’Brien, K. A., Carter, C. G., & Eyberg, S. M. (2010). Early identification and intervention for behavior problems in primary care: A comparison of two abbreviated versions of Parent-Child Interaction Therapy. Behavior Therapy, 41(3), 375-387. https://doi.org/10.1016/j.beth.2009.11.002

[xxii] Boyle, C. L., Sanders, M. R., Lutzker, J. R., Prinz, R. J., Shapiro, C., & Whitaker, D. J. (2010). An analysis of training, generalization, and maintenance effects of Primary Care Triple P for parents of preschool-aged children with disruptive behavior. Child Psychiatry and Human Development, 41(1), 114-131. https://doi.org/10.1007/s10578-009-0156-7

[xxiii] Mendelsohn, A. L., Valdez, P. T., Flynn, V., Foley, G. M., Berkule, S. B., Tomopoulos, S., Fierman, A. H., Tineo, W., & Dreyer, B. P. (2007). Use of videotaped interactions during pediatric well-child care: Impact at 33 months on parenting and on child development. Journal of Developmental and Behavioral Pediatrics, 28(3), 206-212. https://doi.org/10.1097/DBP.0b013e3180324d87

[xxiv] Weisleder, A., Cates, C. B., Dreyer, B. P., Berkule Johnson, S., Huberman, H. S., Seery, A. M., Canfield, C. F., & Mendelsohn, A. L. (2016). Promotion of positive parenting and prevention of socioemotional disparities. Pediatrics, 137(2). https://doi.org/10.1542/peds.2015-3239

[xxv] Center of Excellence for Infant and Early Childhood Mental Health Consultation. (n. d.). About infant and early childhood mental health consultation. https://www.samhsa.gov/sites/default/files/programs_campaigns/IECMHC/about-infant-and-early-childhood-mental-health-consultation.pdf

[xxvi] Bettencourt, A. F., & Plesko, C. M. (2020). A systematic review of the methods used to evaluate child psychiatry access programs. Academic Pediatrics, 20(8), 1071-1082. https://doi.org/10.1016/j.acap.2020.07.015

[xxvii] Hilt, R. J., Romaire, M. A., McDonell, M. G., Sears, J. M., Krupski, A., Thompson, J. N., Myers, J., & Trupin, E. W. (2013). The Partnership Access Line: Evaluating a child psychiatry consult program in Washington State. JAMA Pediatrics, 167(2), 162-168. https://doi.org/10.1001/2013.jamapediatrics.47

[xxviii] Godoy, L., Carter, A. S., Silver, R. B., Dickstein, S., & Seifer, R. (2014). Infants and toddlers left behind: Mental health screening and consultation in primary care. Journal of Developmental and Behavioral Pediatrics, 35(5), 334-343. https://doi.org/10.1097/DBP.0000000000000060

[xxix] Gleason, M. M. (2018). Infant mental health in primary care. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (4th ed., pp. 585-598). Guilford. https://massaimh.org/wp-content/uploads/2020/02/Chapter36PrimaryCare.pdf

[xxx] Briggs, R. D., Stettler, E. M., Silver, E. J., Schrag, R. D., Nayak, M., Chinitz, S., & Racine, A. D. (2012). Social-emotional screening for infants and toddlers in primary care. Pediatrics, 129(2), e377-384. https://doi.org/10.1542/peds.2010-2211

[xxxi] Briggs, R. D., Silver, E. J., Krug, L. M., Mason, Z. S., Schrag, R. D. A., Chinitz, S., & Racine, A. D. (2014). Healthy Steps as a moderator: The impact of maternal trauma on child social-emotional development. Clinical Practice in Pediatric Psychology, 2(2), 166-175. https://doi.org/10.1037/cpp0000060

[xxxii] Molnar, B. E., Lees, K. E., Roper, K., Byars, N., Mendez-Penate, L., Moulin, C., McMullen, W., Wolfe, J., & Allen, D. (2018). Enhancing early childhood mental health primary care services: Evaluation of MA Project LAUNCH. Maternal and Child Health Journal, 22(10), 1502-1510. https://doi.org/10.1007/s10995-018-2548-4

[xxxiii] Ibid.