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 Dr.
Montgomery-Reagan, a pediatrician with University
Medical Associates and the Ohio University College
of Osteopathic Medicine (OUCOM), was concerned about
Sarah Anderson.
Sarah had repeated Kindergarten twice and was still
experiencing academic and social difficulty in the
first grade. Her parents Abby and John were at a
loss for what to do. Dr. Montgomery-Reagan referred
the Andersons to Sue Meeks, a registered nurse and
well child and behavioral health specialist with the
Community Health Services program of OUCOM. During
Sue’s intake interview with Abby and John, they
 discussed
some of Sarah’s difficulties at school. She was
generally inattentive in class, often sat
day-dreaming, and had difficulty forming
relationships and communicating appropriately with
adult figures and peers. As a result, Sarah usually
could not complete tasks and was falling
increasingly behind developmental standards. As Sue
talked with the Andersons, it became increasingly
clear that at an early age Sarah had witnessed
physical violence and drug abuse. Although Abby and
John fought for two years for custodial rights of
Sarah, she remained in the care of her biological
mother Anne for the first three years of her life.
During that time, Anne was physically abused by her
then husband in the presence of Sarah. By the time
Children’s Services removed Sarah from her mother’s
care, she was malnourished, depressed, anxious, and
generally unable to bond with other people. Sue
stressed to Abby and John, “Witnessing this sort of
violence generally has the same sort of impact as
abuse itself. It is possible that Sarah is
experiencing a form of post-traumatic stress
disorder. What is important for you to understand is
that Sarah’s responses are quite normal responses to
very abnormal and traumatic circumstances.”
With tears in her eyes,
Abby lamented, “Sarah doesn’t seem to trust anybody,
she thinks everybody lies to her. We know something
is very wrong, but we don’t know where to start.”
Sue immediately reassured the Andersons, “I don’t
blame her. I probably wouldn’t trust others either.
But we are here to help Sarah and you get the help
your family needs.” As a family navigator, Sue’s job
is to be a primary point of contact for the
Andersons and ensure that Sarah can access the
medical resources she needs. During the intake
interview, Sue asked the Andersons’ about Sarah’s
basic health and developmental history including
speech, language, and hearing abilities, sleeping
and eating patterns, toilet training, chronic
illnesses, motor coordination, school and social
history, and current behaviors. “I don’t believe
that we can just focus on Sarah,” stressed Sue, “we
must also address family history and factors that
may relate to Sarah’s difficulties.” Sue then
explored the medical histories of Sarah’s extended
family including traumatic events, mental health
diagnoses, physical and sexual violence, alcohol and
drug abuse. After identifying the health care
providers that previously had worked with Sarah, Sue
went to work connecting the Andersons with other
health care providers including an early childhood
mental health specialist at Tri-County Mental Health
Services and a speech, language and hearing
specialist at Ohio University. Sue patiently
explained why these referrals were important and
answered questions about symptoms and medications
for conditions like anxiety, post traumatic stress
disorder, and attention deficit disorder (ADD). “It
is critical for Sarah to have a thorough mental
health evaluation because many of the same behaviors
are associated with anxiety, ADD, and post traumatic
stress disorder. A thorough evaluation will help
ensure a correct diagnosis.” Sue also provided the
Andersons with information about their legal rights
to a multi-factorial evaluation (MFE) of Sarah at
school. After signing a release form allowing Sue to
share Sarah’s medical history with other providers,
John sighed, “For the first time in a long time, we
have hope. Thank you.” (Field notes)
r.
Montgomery-Reagan and Sue Meeks, RN,C are
members of the board of directors of the
Integrating Professionals for Appalachian
Children (IPAC). IPAC is a rural health network
composed of university, community, and consumer
partnerships aimed at strengthening Southeastern
Ohio’s health care delivery system to meet the
needs of Sarah Anderson and children like her.
After the initial referral from
Montgomery-Reagan, Meeks developed a
comprehensive care plan for Sarah that included
her family and the expertise of a pediatrician,
early childhood mental health specialist,
physical therapist, educators, and a speech,
language and hearing specialist. As an IPAC
frontline provider, Meeks will continue to serve
as the Anderson’s primary point of contact as
professionals work interdependently to address
the complex challenges facing Sarah.
The federal Health Resources
and Services Administration’s Office of Rural
Health Policy has awarded a three-year, $540,000
grant to Ohio University to support the IPAC
network. IPAC serves children and their families
in Athens, Meigs, Hocking and Vinton counties in
Ohio. The population of these counties
approaches 127,000 people, including 7,021
children between the ages of 0 and 5 (U.S.
Census, 2005;
http://quickfacts.census.gov/qfd/states).
Like the broader region of Appalachia, these
counties are characterized by higher levels of
unemployment and poverty and lower levels of
education in comparison to national baselines (http://factfinder.census.gov).
All four of these counties are federally
designated as medically underserved areas.
Residents of these counties generally have less
access to mental health care due to few material
resources, experience geographic isolation from
mainstream medical infrastructures, and face
uneven distribution of health care providers
across rural and urban settings.
Rural health networks like
IPAC offer an alternative way to organize mental
health care resources for traditionally
underserved populations. IPAC includes thirteen
community agencies in addition to several Ohio
University departments and clinics that provide
professional training and services (for a
complete list of partners, see
http://www.oucom.ohiou.edu/ipac/partners.html).
By integrating their clinical expertise and
resources, IPAC affiliates offer coordinated and
comprehensive services that address early
childhood mental health issues and concerns.
Over the next three years, IPAC members will
develop more fully a family care navigator
program including intake mechanisms and
protocols, facilitate interdisciplinary mental
health assessments and comprehensive care plans
for children, develop an infrastructure for
scheduling and billing of support providers
employed by different agencies, and expand
training of childcare and healthcare providers
to screen children regularly for social and
developmental risk.
Importantly, IPAC members are
integrating mental health care assessments and
services into settings where young children
already are including primary care offices,
preschools, and childcare centers. Sherry
Shamblin, P.C.C., an early childhood mental
health specialist employed by Tri-County Mental
Health and Counseling Services and board member
of IPAC, underscored the importance of bringing
mental health specialists into environments
already inhabited by children, “There are not a
lot of people who have expertise in serving
young children in any kind of specialized
service like mental health, particularly in
southeastern Ohio. But by bringing mental
health care specialists into childcare centers
and having them provide consultation or training
to teachers, then you are shoring up services to
address mental health concerns and you are
developing the capacity of other frontline
providers like teachers. The impact is huge
compared to just keeping a mental health care
provider in a clinic.” Teachers at the
Hocking-Athens-Perry Community Action Head Start
Program, one of many programs served by Sherry,
couldn’t agree more. Beth Helber, a teacher at
the Athens Head Start site, shared, “It is just
incredible to have Sherry come in and observe
our teaching in the classroom and give us
pointers about things we could do when we are
talking to the children and ways to manage
different things. I just really appreciate her
work.  I’ve
talked with
 other
people in centers in the region and they don’t
have access to a mental health specialist and
really feel like they need one. So, I feel
extremely lucky. This resource is just critical
to what we do.”
Teachers at the Athens Head
Start provided numerous examples of successful
interventions facilitated by Sherry. Consider
the following story told by Jennifer Cain,
“Recently, we had a little boy who just couldn’t
concentrate, and he would fight and kick. He
wasn’t even able to really be part of the
classroom for very long. And Sherry came in and
we did some screening evaluations. We worked
with his parents, and talked about different
options and finally referred him to a doctor. He
is on medication now, and made the transition to
kindergarten better than he would of otherwise.”
Jody Hart narrated a similar story, “Addison was
my shadow for two months, and constantly wanted
her mother. She would not leave my side. And
through our consultations, we figured out that
she was dealing with an anxiety problem. Sherry
helped us create a schedule for her that made
her feel more comfortable with the routine of
the day—we are going to do this first, and this
next, and this next, and then it will be time
for Mommy to come get you. We did things to
reassure her that at the end of the day, she
could count on her Mom coming to get her. We
also had a picture schedule, so that the little
girl could go over and look at pictures of what
was going on. She could go to her cubby and see
that after snack her mom would come get her. We
worked with the mom too to make sure she had
transition objects, something of mom’s in her
pocket that made her feel more comfortable
without her mom there. We had a picture of her
mom here in case she just needed to see it. All
of this was to help her feel like school was a
safe place, because we weren’t sure she felt
like that in the beginning.” In reflecting on
the coordinated interventions for Addison,
Sherry emphasized, “There is comfort in the
routines we created. I think it made Addison
feel safer in this environment when she knew
what was going to happen. And if she had shown
up in kindergarten without having had any
interventions, she probably would have fallen
through the cracks. But she moved on to
kindergarten and didn’t have a bit of problems.”
The diverse partners and initiatives
of IPAC are united by their emphasis on early
childhood mental health care interventions.
Consider Sue Meeks’ testimony, “Whenever we get
afraid or threatened or worried, the physical
response from early childhood traumas comes
right back. So, catching those things early is
critically important. Straightening out kids’
responses early will prevent the sort of
engrained and automatic responses that become so
habitual over the years that it becomes more
difficult to break the older they get. It’s no
different than other medical fields. If you have
cancer and you catch it early, you have a better
chance of successful treatment. If you have
diabetes, and you have early intervention, you
are probably going to have a better outcome.
It’s the same with mental health. You lose time
if you don’t catch it early. Kids often learn to
read or speak at certain times, and once that
time is gone, it becomes much harder for it to
be that easy for the child again.” Sherry
Shamblin agreed, “If we are able to intervene
when kids are young, we are going to be able to
prevent more severe problems from developing
when the kids are older. We can help provide a
more solid foundation that will benefit them for
the rest of their lives.”
We live in an age of limits.
Scarce resources and services related to early
childhood mental health led rural community
agencies and university partners in southeastern
Ohio to form IPAC. Children and families are
already realizing the benefits of this rural
health network. The Anderson family is able to
access the interprofessional services that Sarah
needs. Children and families involved with the
Hocking-Athens-Perry Community Action Head Start
Program receive on-site mental health care
assessment and treatment through coordinated
efforts with Tri-County Mental Health and
Counseling Services. In reflecting on the
benefits of IPAC, Sherry Shamblin stressed, “By
forming the network, we have become a more
powerful and collective voice that has allowed
us to access funding and to integrate services
so families can have more streamlined and
successful services. What we found prior to IPAC
is that people were really in their own silos
doing their own thing, and we had families who
went here, then went there, then went here, then
went there over a period years and still really
never knew what was going on with their child.
So the network approach has already made a
difference.” Sue Meeks credits IPAC’s success in
part to the passion and commitment of its
affiliated partners, “I think what is special
about IPAC is that we all have similar passions.
It may not be coming from the same place, and
the passion may not be aimed at the same thing,
but we’ve been successful because we all care
deeply about mental health issues. Every single
one of us is passionate about what we do. And
you just can’t fail when you have that much
passion sitting around one table.” The Ohio
Department of Health acknowledged the success of
IPAC by awarding the network the annual
Distinguished Rural Health Program Award in
September of 2007.
To learn more about IPAC,
please contact Dr. Jane Hamel-Lambert, President
of IPAC and a faculty member in the Department
of Family Medicine at Ohio University’s College
of Osteopathic Medicine (hamel-lj@ohiou.edu), or
John Borchard, RN, BSN of the Southern
Consortium for Children and chairman of the IPAC
Board of Directors (jborchard@scchildren.com).
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