Review of Mental Health Referral Data Highlights Patterns—and Gaps—in 0-5 Care
Mental health challenges are common in children in the birth-to-5 age range and often co-occur with medical conditions. However, the tools and diagnostic criteria frequently used for older children and adults, like the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), aren’t intended for infants and young children.
A resource called the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–5) was developed in the 1990s, and updated in 2016, to more accurately assess and care for patients aged birth to 5 years. While DC:0-5 includes robust diagnostic criteria, there’s a lack of awareness of the resource in the mental health field.
Marian E. Williams, PhD, Clinical Psychologist and Director of the Stein Tikun Olam Early Connections Program at Children’s Hospital Los Angeles, recently published a study analyzing DC:0-5 data gathered during the intake process for the hospital’s Medicaid-funded Community Behavioral Health Program. Co-authors for the study are Tiffany Vo, PsyD, a recent graduate of CHLA’s Clinical-Child Psychology Fellowship, and Bryan Lei, a research staff member in the Biostatistics and Data Management Core at The Saban Research Institute.
The study looked for patterns in referrals, diagnoses, and care—and explored potential gaps where young patients and their families may need additional resources.
About the study
For more than 35 years, the Community Behavioral Health Program has provided diagnosis, evaluation, and treatment for infants, children, and youth at Children’s Hospital Los Angeles. Children come to CHLA via referrals from various sources throughout L.A. County, whether through a pediatrician, the child welfare system, or a preschool.
The researchers conducted a chart review of DC:0-5 intake assessment data from 627 children aged birth through 5 years who were referred to CHLA for Medicaid-funded mental health services. The study compared 402 children with any medical concern or condition alongside 195 children with no medical concerns.
“We wanted a better understanding of who we are serving,” explains Dr. Williams. “What are their needs? What are the most common reasons young children come to therapy—and what we might be missing?”
The team then analyzed the data to identify common disorders, areas of need, and potential gaps in care. Here’s what they found:
Most common disorders
About 37% of children in the birth-to-5 age range referred to the Community Behavioral Health Program were diagnosed with a trauma, stress, or deprivation disorder. Neurodevelopmental disorders were also common, with about 30% of children having a disorder such as global developmental delay or autism spectrum disorder. Other common disorders, which affected 15-17% of the population, included mood disorders and anxiety disorders.
Developmental delays frequently coexisted alongside mental health needs.
Most participants were noted to have inconsistent or delayed development across emotional, social-relational, language/and communication, and cognitive areas.
“When you're talking about a young child, you really can’t isolate development from behavior,” says Dr. Williams. “Whether it's delays in language, motor skills, or adaptive skills, people working with this age group should assess all aspects of the child’s development and behavior in an integrated manner.”
Boys were more likely to be referred than girls.
The patient population referred to mental health services was 68% male, which doesn’t match the hospital’s relatively even distribution of boys and girls.
Dr. Williams explains that children who exhibit more outward displays of mental health challenges, like aggression or hyperactivity, may be more likely to receive referrals than children who internalize their challenges. Often, this can include more boys than girls.
“That makes us wonder if kids who are more quietly suffering are getting missed,” says Dr. Williams. “Healthcare providers tend to be really good at identifying the need for mental health services for the kids who have obvious behaviors—someone who is sitting on their hospital bed chucking objects at anyone who opens the door—versus someone more reserved.”
Referrals to the Community Behavioral Health Program skewed older.
Around 45% of children in the 0-5 age range referred to the Community Behavioral Health Program were 4 or 5 years old, indicating a potential gap in care for the youngest children.
“It could be that younger children don’t need mental health services, but it’s more likely that people don’t think of referring them or even know that Infant Family Mental Health Care exists for young children,” explains Dr. Williams.
Universal mental health screenings helped connect younger children with mental health care.
Referrals for children under 4 most commonly originated from inpatient settings like the Newborn and Infant Critical Care Unit, where embedded psychologist, Angelica Moreyra, PsyD, can proactively identify families in need of infant-family mental health services. This highlights the power of universal screening programs to reach patients who may have previously fallen through care gaps.
For the last 10 years, Dr. Williams’ team has provided infant-family mental health care at CHLA for infants and families in critical care settings and for those with the highest levels of need. This year, Dr. Williams and co-Director, Melissa Carson, PsyD, launched the Stein Tikun Olam Early Connections Program, which aims to expand those services to all patients from birth to 3-years-old who receive specialty medical care at CHLA. This program will be one of the first–of–its kind in the nation to provide universal, hospital-wide infant-family mental health services.
“Universal screening ensures that we at least provide a light touch to every family in our care,” explains Dr. Williams. “It allows us to have a conversation with the family, see what their concerns are, and identify who needs additional follow-up and therapy versus who may need tips for getting their child to sleep or helping them through their hospitalization.”
Increasing awareness of DC:0-5 for pediatric psychologists
The study results highlight the importance of training and education on early screening and identification of mental health symptoms for children with and without chronic medical conditions.
“Pediatric psychologists are generally expected to be able to work with any age—but they don’t always have the right tools available,” says Dr. Williams. “If we can get more mental health providers who work with young children to use DC:0-5 consistently, this could enable more young children to receive the treatment they need early in life."
