This document discusses the cost-effectiveness of evidence-based interventions for children and families. It provides data showing high rates of mental health issues among children in foster care and the overlapping symptoms between trauma and mental illnesses. The document advocates replacing ineffective approaches with trauma-focused cognitive behavioral therapy, parent-child interaction therapy, and other evidence-based approaches that are already reimbursed by Medicaid in some states. Screening tools and standardized assessments of social-emotional needs are also recommended. The goal is improved outcomes by addressing the social and emotional needs of children and families in a proactive, developmentally-appropriate manner.

1. Buying What Works Pays Off: Cost-
Effectiveness of Evidence-Based
Interventions
BRYAN SAMUELS, COMMISSIONER
ADMINISTRATION ON CHILDREN, YOUTH & FAMILIES

2. CMS ENCOURAGES USE OF EPSDT TO IDENTIFY
TRAUMA AMONG CHILDREN WHO HAVE BEEN
MALTREATED
• CMCS Informational Bulletin
dated March 27, 2013:
Prevention and Early
Identification of Mental Health
and Substance Use Conditions
• Highlights that “Children exposed to trauma, including
maltreatment, family violence, and neglect, exhibit symptoms
consistent with individuals diagnosed with post-traumatic stress
disorder, attention deficit/hyper-activity disorder, depression, and
conduct disorder/oppositional defiant disorder.”
• Outlines elements of EPSDT benefit that are particularly relevant to
prevention and detection of mental health and substance abuse
disorders.
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3. MENTAL HEALTH IN CHILD WELFARE
MH Prescriptions MH Services Any MH Use
70%
60%
50%
40%
30%
20%
10%
0%
Ages 0-5 Ages 6-11 Ages 12+
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Data Source: USDHHS

4. MOST COMMON MENTAL HEALTH DIAGNOSES AMONG
CHILDREN IN FOSTER CARE RECEIVING
PSYCHOTROPIC MEDICATIONS
40%
30%
20%
10%
0%
ADHD Depression Conduct/ Bipolar Disorder
Oppositional
Defiant Disorder
Zito, JM; et al. (2008). Psychotropic medication patterns among youth in foster care.
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Pediatrics. 121(1): e157.

5. MEDICAID IS ALREADTY PAYING FOR TRAUMA
INTERVENTIONS: SYMPTOMS THAT OVERLAP WITH CHILD
TRAUMA AND MENTAL ILLNESS
Mental Illness Overlapping Symptoms Trauma
Restless, hyperactive, disorganized, and/or
Attention Deficit/ agitated activity; difficulty sleeping, poor
Child Trauma
Hyperactivity Disorder concentration, and hypervigilant motor
activity
Oppositional Defiant A predominance of angry outbursts and
Child Trauma
Disorder irritability
Anxiety Disorder (incl.
Social Avoidance of feared stimuli, physiologic and
Anxiety, Obsessive- psychological hyperarousal upon exposure
Compulsive to feared stimuli, sleep Child Trauma
Disorder, Generalized problems, hypervigilance, and increased
Anxiety Disorder, or startle reaction
phobia
Self-injurious behaviors as avoidant coping
Major Depressive
with trauma reminders, social withdrawal, Child Trauma
Disorder
affective numbing, and/or sleeping difficulties
(Griffin, McClelland, Holzberg, Stolbach, Maj, &Kisiel , 2012)
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6. ESTABLISHING A COST-EFFECTIVE SERVICES ARRAY
Current Investments Replacement Investments
Triple P – Positive
Parenting Classes
Parenting Program®
De-scaling Investing
what doesn’t Fluoxetine Trauma-Focused in what
work (Psychotropic Cognitive Behavior does
Medication) Therapy (TF-CBT)
Child-Parent
Generic Counseling Psychotherapy
(CPP)
INEFFECTIVE RESEARCH-BASED
APPROACHES APPROACHES
How much it would What is currently The amount needed
CALCULATION cost to implement a minus being spent on an
= upfront to implement
particular evidence- ineffective the evidence-based
based intervention intervention to try to intervention
address the issue(s)
In Year 3, 4 and/or 5: Expected savings due to improved child and family
outcomes from use of evidence-based intervention(s) to address the issue(s)
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7. AROUND THE COUNTRY: EBPs REIMBURSED BY
MEDICAID
Multidimensional Treatment Foster Care (MTFC)
• Hawaii, Nebraska, California, Tennessee
Parent-Child Interaction Therapy (PCIT)
• New Jersey, Delaware, Iowa, DC, Illinois, Oklahoma
Multisystemic Therapy (MST)
• Tennessee, New Jersey, Arizona, DC, New Mexico
Functional Family Therapy (FFT)
• New Jersey, Louisiana, DC, Washington
Cognitive Behavioral Therapy (CBT)
• New Jersey, North Carolina, Delaware, South Carolina
Incredible Years (IY)
• Oregon, Florida, Texas, New York
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8. SCREENING AND ASSESSMENT UNDER EPSDT
“[Massachusetts] implemented new
regulations requiring primary care
providers to screen for developmental
and behavioral problems for all
MassHealth members younger than 21
years. Providers are required to use
validated, standardized screening
tools from a list provided by the
state and are currently reimbursed
approximately $10 for each
screening test performed and an
additional $25 for face-to-face
evaluation and management time for
a positive screen. Prior to these
regulations, even the mandated
screening under EPSDT did not require
the use of specified tools and was not
a distinct, uniformly reimbursable
service.”
Kuhlthau, K; Jellinek, M; White, G; VanCleave, J; Simons, J; & Murphy, M. (2011). Increases in
behavioral health screening in pediatric care for Massachusetts Medicaid patients. Archives of Pediatric 4/16/2013 8
and Adolescent Medicine. 165(7):660.

9. A COMMITMENT TO PROMOTING WELL-BEING FOR
CHILDREN AND FAMILIES MEANS:
1. Focus on child & family level outcomes
2. Monitor progress for reduced symptoms and
improved child/youth functioning
3. Proactive approach to social and emotional needs
4. Developmentally specific approach
5. Promotion of healthy relationships
6. Build capacity to deliver EBPs
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