Columbia University Mailman School of Public Health

Minnesota

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Strategies

Child Social-Emotional Screening and Response

Minnesota has developed a comprehensive system of policies and supports for social-emotional screening of infants, toddlers, and preschoolers. Social-emotional screening is promoted in pediatric settings through the state’s EPSDT program and several other initiatives that serve young children, including: the Follow Along Program for children birth to 36 months; the Minnesota Department of Education’s Early Childhood Screening Program for three-year-olds through kindergarten-aged children; Early Head Start and Head Start; and child welfare which requires social-emotional screening of young children who receive protective services or are in out-of-home placements. Clear policies and protocols help ensure effective screening across programs in this system.

  • Guidance for providers in pediatric settings recommend a minimum of seven social-emotional screenings through age four, with additional social-emotional screenings provided and billable, as needed.
  • In the Follow Along Program, operated through local public health departments, a nurse or other professional invites parents (by phone or a home visit) to complete ASQ-SE and ASQ screenings on a regular basis, shares results with parents, and helps them connect with a provider for an evaluation if social-emotional or developmental concerns are identified.
  • All children are required to have social-emotional and developmental screening for participation in kindergarten programs and can receive these through the MN Department of Education’s Early Childhood Screening Program for three-year-olds through kindergarten-aged children; outreach materials are translated into seven languages.
  • Children who receive protective services or are in out-of-home placement must receive a mental health screening with the ASQ-SE or Pediatric Symptom Checklist, and follow-up diagnostic assessment and treatment if needed; these children are typically screened by the child welfare agency.

The Minnesota Interagency Developmental Screening Task Force conducts rigorous reviews of child screening instruments and provides guidance on developmental and social-emotional screening of children from birth through five for public screening programs. Members of the Task Force include representatives from the Departments of Health, Human Services, and Education. The Task Force has created online guidance about recommended screening instruments. This guidance identifies the Ages and Stages Questionnaires: Social-Emotional, 2nd edition (ASQ:SE-2) as the recommended screening tool for children under age four and the Pediatric Symptom Checklist and ASQ:SE-2 for children ages four and five in public screening programs.

The Task Force also offers guidance on referral and follow-up for young children who have positive social-emotional screens. One resource explains how primary care and school-based providers (e.g., preschool, preschool special education) can share child-specific data to coordinate referrals based on HIPAA and FERPA (federal health care and educational data privacy laws). Providers and staff in pediatric settings, early care and education, child welfare, home visiting, as well as parents, are encouraged through multi-language outreach materials to refer children for screening and follow-up services through the state’s Help Me Grow (HMG). In Minnesota, HMG connects families to the child’s local school district for further screening, evaluation and service coordination. The Task Force has developed training resources on social-emotional screening. These include a curriculum with PowerPoint slides and notes that cover developmental and social-emotional screening, referral, and linkage to services as well as web-based and in-person trainings.

Financing

Sources for funding to conduct screening include Medicaid, Title V, Part C (IDEA), and state appropriation.

Monitoring and Evaluation

Most public screening programs in Minnesota collect annual data on the number of children screened by characteristics that include age, race/ethnicity, and primary language, as well as referral rates. In 2018, school districts screened 64,000 children statewide; the screening rates among three- and four-year-olds were 38% and 34%, respectively. Head Start completed 17,000 screenings in 2018, and public health completed 10,500. The social-emotional screening rates in EPSDT visits were 14% for infants (under 1 year), 8% for children ages 1-2 years, and 16% for children ages 3-5 years in 2017. The screening rates may be under-reported as many providers are not aware that the state’s Medicaid covers social-emotional screens (unlike private insurance), and are not billing Medicaid for those screens.

An evaluation of screening and referral practices in pediatric settings examined practices that had participated in an ABCD project which promoted screening with training and resources. This project, a retrospective medical record review of five primary care clinics, found that practices incorporated evidence-based social-emotional and developmental screening into their practices and made frequent referrals to HMG based on screening and parent concerns. However, documentation of follow-up to ensure completion of the referral and outcome was less consistent; for about one-quarter of the referred children, there was no follow-up information in charts.

Effective Assessment and Diagnosis (DC:0-5)

The Minnesota manual for Medicaid providers recommends that mental health professionals conducting diagnostic assessments use the Diagnostic Classification of Mental Health Disorders of Infancy and Early Childhood with children under age 5. In July 2018, the state officially established a requirement for providers’ use of the current version, DC:0-5, and is in the process of revising statute language to reflect the change. The State has developed a cross-walk between DC:0-5 and ICD codes to facilitate billing. Prior to a standard diagnostic assessment, clinicians have the option to conduct three pre-diagnostic assessment sessions and collect all necessary information specified under the DC:0-5 framework. Alternatively, a clinician can conduct and bill for an extended assessment conducted over three or more sessions.

Training on the DC:0-5 is offered through the state’s Adult & Children’s Mental Health Learning Center. An in-person introductory course on the DC:0-5 consisting of three full-day sessions is offered five times throughout the year. The first day of the course focuses on child development, and the subsequent days cover DC:0-5 and Medicaid compliance. Clinicians who complete the DC:0-5 training can participate in a free consultation group for additional support. The consultation group, called “Great Start Clinician’s Group,” meets via teleconference every month. Up to 300 participate monthly in the Great Start Clinicians’ Group. The group provides opportunities for clinicians to discuss cases, especially difficult ones, and hone their assessment skills. In addition, the Minnesota Department of Human Services has created additional diagnostic resources to assist clinicians, including Diagnostic Assessment Decision Tree for Children 0-5 and How to Gather Information for the DC:0-5 Five Axes. By August 2019, the state had trained 3,000 mental health professionals in the use of DC:0-5.

In an effort to build the workforce, Minnesota allows clinical trainees to conduct diagnostic assessments and bill at the same rate as their supervisors. The state Medicaid clearly defines who qualifies as clinical trainees in its provider manual. In addition, the Behavioral Health Division launched an effort to train university faculty on DC:0-5 in 2016. Faculty participating in the training came from 11 different universities across the state and represented the fields of psychology, psychiatry, developmental pediatrics, social work, clinical counseling, and marriage and family. The one-day training integrated the Zero to Three curriculum.

Financing

The state funds all DC:0-5 trainings and the Great Start Clinician’s Group meetings through its Federal Mental Health Block Grant. Providers who are early childhood mental health grantees can receive payment for billed hours they lose to training participation through a state appropriation.

Special thanks to Catherine Wright, Early Childhood Mental Health System Coordinator, Behavioral Health Division, Minnesota Department of Human Services, for providing information for and reviewing this profile.