A mother, frantic with worry, brought her newborn in for a checkup at the pediatric clinic at San Francisco General Hospital. But there wasn’t anything wrong with the baby. And over the next several months, no amount of reassurance could convince the mom that her child was eating, sleeping and growing just fine. If anything, the mother’s worry led to behavior that raised alarm bells for her health care providers.
“[The family] wasn’t returning calls from the provider, and they were withdrawing from care,” says Dr. Kate Margolis, a psychologist and associate director of primary care behavioral health in pediatrics at S.F. General.
To determine the causes of the mother’s profound concern, she was referred for behavioral therapy with HealthySteps specialists at the Children’s Health Center at S.F. General. HealthySteps is a national program that provides therapy for maternal depression, as well as support with positive parenting techniques and navigating the challenges of parenting for low-income families of babies and young children at their doctor’s office.
Until now, families in California’s Medicaid program, known as Medi-Cal, would not have been able to receive the intensive therapy through HealthySteps unless clinics had grant support for it. But this summer, Medi-Cal announced a new Family Therapy Benefit that changes the entire mental health landscape in California. It allows families to obtain preventive therapy for an unlimited number of sessions if parents, like the worried mother at San Francisco General, are experiencing stress that affects their children. The coverage, which applies retroactively to the beginning of 2020, for the first time essentially elevates mental health to the same level of support as physical health.
“It allows over half of the population that we see in primary care to be able to access mental health services they otherwise wouldn’t be able to,” says Margolis.
Besides mental health challenges in a parent, eligibility for the benefit also applies to California youth under the age of 21 who have experienced a wide range of stressful events, including being “separated from a parent due to incarceration or immigration,” experiencing the “death of a parent; foster home placement; exposure to domestic violence or other traumatic events; severe or persistent bullying and the experience of discrimination based on race, ethnicity, gender identity, sexual orientation, religion, learning difference or disability.” Youth are also eligible for therapy through the Family Therapy Benefit if they lack sufficient food and/or access to stable housing.
If that list seems familiar to those of you who know about the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) list of ACEs, you’d be right. The experiences listed in the Family Therapy Benefit were adapted from the ACE Study and expanded ACE surveys. The ACE Study linked ACEs to the adult onset of many chronic diseases, mental illness, violence and being a victim of violence in more than 17,000 adults. The study found that ACEs are remarkably common — most people have at least one. People who have four or more different types of ACEs — about 12 percent of the population — have a 1200 percent higher risk of attempting suicide and a 700 percent higher risk of becoming an alcoholic, compared with people who have no ACEs.
The epidemiology of childhood adversity — which produce ACE surveys — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
The need for addressing and preventing mental health problems in California’s children couldn’t be clearer. In a state-by-state ranking of the mental health status of youth that was recently released by Mental Health America, California ranked 33rd. To Alex Briscoe, a mental health practitioner and principal for the San Francisco-based California Children’s Trust, the fact that Medi-Cal has broadened its eligibility requirements to include life experiences for family therapy is a true game-changer.
“For the first time in the history of the public mental health system, you can qualify for social and emotional support without a diagnosis,” he says. Looking back on his career as a therapist, Briscoe says, “The vast majority of the children and families that I have worked with and served were not pathological, and were not mentally ill. They were dealing with the reality of living in a culture that tells them they're worth nothing, that constrains their opportunities. And their behavior was a totally reasonable and rational response to those realities. But in order to provide support, I had to give them a diagnosis.”
More pointedly, Briscoe says, “Perhaps most important to the broader [social justice] movement is that the [eligibility requirements] acknowledge the impact of race and poverty on the social and emotional welfare of Medi-Cal beneficiaries.”
Selena Wilson, vice president of organizational effectiveness at the East Oakland Youth Development Corporation, agrees that the change is huge because families have always had to get a diagnosis for their child to get support even if their behaviors were tied to what was happening to them in the community.
“And unfortunately, the ripple effect of that was misdiagnoses and the pathologizing of a lot of black and brown kids,” she says.
The Family Therapy Benefit directly complements another program that began this year in California. In January, the state started rolling out a universal program to identify adverse childhood experiences in pediatric patients in the state’s Medi-Cal program. The ACEs screening questionnaire, known as the PEARLS tool (it stands for Pediatric ACEs and Related Life events Screener), uses the same language as the Family Therapy Benefit’s eligibility requirements. It asks whether the children have witnessed domestic violence in the home, experienced the death of a parent, experienced discrimination, whether they have been placed in the foster care system, have been bullied or have experienced unstable housing, among other challenges to basic survival.
Indeed, the Family Therapy Benefit is one way that California will be able to help prevent ACEs in the next generation. In the most practical application of that, it removes several barriers that interfere with the ability of marginalized communities to get help, since it means they no longer have to juggle separate appointments.
“When people lack transportation and don’t get paid leave time from work, they are going to prioritize their basic needs over something like therapy,” says Margolis. But going to the pediatrician’s office, she says, “is something that’s already baked into our culture. You go to the doctor for your kid’s checkup, and they’ll take the time for that.”
In the case of the mother who was assessed by the HealthySteps specialist at S.F. General, those visits revealed that the mother was suffering from anxiety and depression, says Margolis, who oversees the clinic’s HealthySteps program. The provider also screened her for ACEs, and found she was dealing with childhood trauma.
“A caregiver with a history of trauma has a lot of trouble soothing themselves,” says Margolis. Further discussion revealed that mother’s parents were deeply critical of her parenting, further eroding her confidence and resulting in her being hypervigilant with her baby. That behavior can interfere with a child’s self-confidence and willingness to explore their environment, Margolis explains, which is a critical aspect of development.
Over time, the therapist has helped the mother learn to separate the stress from her own childhood trauma and to use calming techniques like deep breathing when she feels triggered. The mother is also becoming better able to read her baby’s cues and to tell if she needs extra comfort or is doing just fine.
“The mother was reporting less anxiety, and many fewer concerns about her child's health. So, her views about how her baby was doing started to line up with the health care providers’ views,” notes Margolis. And this means that the baby will likely develop along a healthier trajectory.
To Margolis, what’s most striking about the new Family Therapy Benefit is that it can help prevent the transmission of ACEs—and do so on a very wide scale.