Ask any parent with a young child, and they'll tell you how challenging it can be. Tears, tantrums, and exhaustion are all in a day's work — and that's on a good day. Stress levels climb even higher if a child shows signs of developmental delays, emotional problems, or acting out.
Now add to the mix a parent with serious depression or anxiety, a loss in the family, or any of the many sources of trauma associated with poverty: homelessness, food insecurity, exposure to violence. Any one of these challenges — and they rarely come in ones — can both magnify and overshadow the everyday stress of raising a kid.
"If a caregiver is having a hard time personally, it becomes harder to parent," says Cleisa Gomes, a family partner at Codman Square Health Center, in Dorchester, Mass. "It's harder to communicate with the child. It's harder to be attuned to their needs. It's not anyone's fault. It's just a reality."
Untangling the knot of stressors that can interfere with child development and parental attachment is the core purpose of BRANCH, a new approach to supporting families and addressing behavioral health in early childhood that is now being established in primary care settings at Codman Square and several other community health centers in Massachusetts.
BRANCH, which stands for Building Resilience and Nurturing Children, is a brief and targeted intervention that includes both the child and parent (or another primary caregiver) and involves assessing a child's development, listening to the parent and family's needs, and devising a game plan for connecting the family to specialty care or other supports as needed.
BRANCH is just one in a continuum of services that make up TEAM UP for Children, a model of integrated behavioral health in pediatric primary care that was launched in 2016 and is supported by the Richard and Susan Smith Family Foundation and The Klarman Family Foundation. Based at community health centers, TEAM UP comprises interdisciplinary teams of providers working within a shared framework that combines a focus on early childhood, a broad view of behavioral health that transcends specific diagnoses, and an emphasis on family and community engagement.
"There's a growing recognition of the importance of early childhood in the overall development of healthy children and young adults," says Emily Feinberg, a pediatric nurse practitioner and the director of TEAM UP. "BRANCH is a recognition that primary care is a really important space to begin to think about the social-emotional needs of very young children and the positive role that primary care clinicians can play in child development."
A flexible take on a well-developed model
The overarching goal of BRANCH is to bolster the capacity of families to be resilient in the face of adversity. The intervention focuses on strengthening the child-caregiver relationship and also addresses the long-term impact of traumatic events and severe, prolonged stress — commonly known as toxic stress — on young children.
Although BRANCH is grounded in established therapeutic models, it's tailored to the pace and culture of primary care and community health centers. Few behavioral health evaluations or brief treatment resources for children under age six have been designed with the health center setting in mind. In a world of back-to-back appointments and competing priorities (for families and providers alike), flexibility is essential. So while BRANCH is drawn up as five to seven 30-minute sessions, the number and spacing of the sessions are intended to bend to the family's needs.
Although BRANCH is grounded in established therapeutic models, it's tailored to the pace and culture of primary care and community health centers.
Likewise, the provider team reflects the needs of the patient population at community health centers. As with TEAM UP as a whole, BRANCH is built around an interdisciplinary three-person team that includes a pediatric primary care provider, an integrated behavioral health clinician, and a family partner or community health worker, like Gomes. After a warm handoff from the primary care physician, the behavioral health clinician and family partner lead the parent and child through the sessions.
At a conceptual level, BRANCH is a strength-based intervention. Though trauma of some kind is sadly the norm among the families who participate in BRANCH, the provider team seeks to spotlight the positive aspects of the child-caregiver relationship and identify concrete supports and services that empower families further.
"BRANCH isn't just about trauma," says Betsy McAlister Groves, early childhood consultant to TEAM UP and the founder of the Child Witness to Violence Project at Boston Medical Center. "It's about relationships, child functioning, and children's and families' needs. It's a deeper way to look at the strengths and challenges that children and families have and then to develop a plan for next steps."
BRANCH in practice
Providers typically initiate BRANCH if a caregiver voices stress or concern about child behavioral problems, such as excessive clinginess, a chronic inability to sit still or focus, aggression with other kids, frequent tantrums, or conflicts at daycare or preschool.
"We offer BRANCH whenever a caregiver is talking about stress, and how stress is affecting their parenting," says Molly Brigham, a licensed clinical social worker who partners with Gomes at Codman Square.
Although the timing and sequence of the sessions is flexible, BRANCH involves some core elements. Following the warm handoff and an initial conversation, the social worker and family partner schedule a 30-minute follow-up visit with the child and caregiver. This first visit is an opportunity to assess the child's development, observe the attachment between child and caregiver, and gain a better understanding of the caregiver's stress and strengths.
The Dimock Center in Roxbury, Mass., is one of several community health centers implementing BRANCH as part of the TEAM UP for Children initiative. (Ray Hainer)
In subsequent sessions — which sometimes include just the caregiver — the providers further explore the family's needs and sources of stress. "It's focused on the kid," says Gomes, "but the kid is our door into supporting the family."
Finally, the providers and caregiver formulate a game plan together. The next steps might include a referral to a behavioral health specialist, or to family therapy, in-home therapy, or services offered by community partners. Just as often, the provider team connects families with Head Start programs or daycare vouchers through the Department of Transitional Assistance or Child Care Choices of Boston.
Building capacity in primary care
Most behavioral health clinicians working in primary care have not received specialized training in child development or behavioral health in early childhood. The BRANCH trainings led by the TEAM UP staff — and the addition of the grant-funded family partner role — are designed to build capacity and confidence within primary care, enabling the staff at community health centers to spend more time assessing young children and caregivers and understanding their specific needs.
"TEAM UP is filling gaps for clinicians and providers and boosting the clinical capacity in-house"
– Marcia Williams-Gupta, LCSW
"TEAM UP is filling gaps for clinicians and providers and boosting the clinical capacity in-house," says Marcia Williams-Gupta, a licensed clinical social worker who uses the BRANCH model at the Dimock Center, in Roxbury, Mass. "Before BRANCH, we would refer children out for developmental pediatrics or in-home therapy, or maybe early intervention, depending on the age. Now we can hold them here, in a therapeutic way, and gather more information before deciding whether we need to make a referral."
TEAM UP is in the process of an initial evaluation of BRANCH, which is focused on the referral process for BRANCH and gathering clinician feedback on the utility of the intervention. In a later phase, TEAM UP will solicit caregiver feedback on the value of BRANCH.
The community health center providers are quick to point out that the positive outcomes they see are driven as much by the families themselves as they are by the BRANCH approach.
"They're amazing and resilient," Brigham says. "We're working with families because the caregiver is interested in support, and that is such a strength. We're only promoting what's already happening.