Ashley Sward, Jennifer King, and Kelly Glaze, University of Colorado School of Medicine; Susanne Klawetter, Portland State University; and Karen A. Frankel, University of Colorado School of Medicine
The coronavirus disease 2019 (COVID-19) pandemic continues to demonstrate far-reaching impact on individuals, families, and communities. Emerging research highlights the detrimental impact of the pandemic on perinatal mental health. Warm Connections is a behavioral health program embedded in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics. The authors describe changes made by Warm Connections to address the increased needs of this population during the pandemic. In collaboration with WIC staff, the program developed a new outreach model to provide timely, comprehensive support for caregivers in the early postpartum period. Included is a case example and an important reminder that systems under stress can find resilience and inspiration in connection and innovation.
Nearly 2 years since the onset of the coronavirus disease 2019 (COVID-19) pandemic, families continue to be dramatically impacted. Prolonged financial insecurity, fears of becoming ill, and disrupted roles and routines are just a few of the daily challenges caregivers may face. Emerging reports indicate that stress levels are particularly high among those who care for children (Park et al., 2020; Pew Research Center, 2020; Twenge & Joiner, 2020) and may confer greater risk of developing symptoms of mental health disorders. In a large-scale international study examining the effects of COVID-19 on perinatal mental health, elevated symptoms of anxiety, depression, and posttraumatic stress were highly prevalent in women across 64 countries, and more than half of all participants showed elevated levels of loneliness (Basu et al., 2021). Another study focused specifically on pregnancy found elevated symptoms of depression and anxiety related to the pandemic, with higher symptom levels associated with concerns regarding health and access to health care, relationship strain, and social isolation (Lebel et al., 2020). Given these alarming global trends, the need for equitable access to mental health care has never been more urgent, particularly for underserved populations.
Warm Connections is an innovative program that integrates several proven developmental/infant mental health approaches in a setting where no other behavioral health services are provided and where thousands of low-income families are seen annually: the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC is a federally administered assistance program providing supplemental, nutritious food; health-related education; and referrals to support other social determinants of health needs across the United States, including 34 Indian Tribal Organizations, Puerto Rico, the Virgin Islands, American Samoa, Northern Mariana, and Guam (Food and Nutrition Services, 2013). Established in 1972 and administered by the United States Department of Agriculture, this widely researched and supported assistance system is the third largest nutrition service program in the United States. Nearly half of all children under 1 year old, and a quarter of all children from 1–4 years old, in the country participate in WIC services, making it an ideal access point for early childhood systems of care (Oliveira & Frazao, 2009).
Underserved families, like many of those who participate in WIC, experience multiple barriers to accessing supportive behavioral health services. Moreover, research indicates that mothers who receive WIC benefits are up to twice as likely to endorse a response of “often” or “always” on one or both of the first two questions of the Patient Health Questionnaire (PHQ) as are mothers who are ineligible for WIC (Pooler et al., 2013). The first two questions of the PHQ-9 inquire how often an individual is “feeling down, depressed or hopeless” and/or experiencing “little interest or pleasure doing things” (Kroenke et al., 2001). Having perinatal mood and anxiety disorders (PMADs) is only one of numerous toxic stressors that WIC families experience by virtue of low income, minoritized status, and/or limited resources. Integrating maternal and infant mental health (MIMH) services into WIC clinics plays a critical role in providing multiple levels of support, prevention, and education for caregivers who may be at risk for depressive symptoms, toxic stress, and/or poor parenting skills.
According to the results of a needs assessment completed by the Warm Connections program prior to starting service delivery, caregivers receiving WIC services at clinics in a large, western, metropolitan city identified their own mental health concerns, stress related to parenting, difficulty accessing community resources, and concerns about their child’s development and behavior as the most salient psychosocial stressors for which they desired support (Klawetter et al., 2020). To address these needs, Warm Connections staffs WIC clinics with highly qualified MIMH practitioners to offer preventive behavioral, social–emotional, and developmental support; conduct PMADs screening, and provide interventions and referrals for positive screens; and link WIC participants to resources within the maternal, infant and early childhood mental health systems of care. These MIMH practitioners are called “Warm Connections Specialists” (WCSs).
Prior to the pandemic, there were several access points to the Warm Connections program for WIC-enrolled families. These entry points included referral-driven urgent concern consultations, brief integrated consultations, and outreach based on elevated PMADs screening. Urgent concern consultations were initiated by WIC staff after identifying an individual or family need. In an attempt to apply a more universal, preventive model, Warm Connections created brief integrated consultations. These consults took place in the context of an already-established WIC appointment chosen based on appointment type rather than identified need. During these consults, the WCS introduced the program, provided developmental guidance, and assessed for and connected the family to needed support. Lastly, WCSs reached out to pregnant and newly postpartum caregivers with elevated Edinburgh Postnatal Depressions Scale screens (i.e., total score of 10 or higher and/or endorsed thoughts of self-harm).
Impact of COVID-19 on WIC Families
Early in the pandemic, caregivers receiving Warm Connections consultation often reported symptoms of anxiety related to worry about contracting COVID-19 and about the community mitigation measures. These measures, such as school and business closures, stay-at-home orders, quarantining, and physical distancing, presented unprecedented hardships. In spring of 2020, fears of being unable to find WIC-approved foods, loss of stable employment, and eviction were common urgent concerns for WIC families. Referrals to food pantries and organizations providing diapers and other baby essentials increased dramatically. Though always an integral part of the Warm Connections model, those referrals became an important port of entry for assessing psychosocial needs. Trained in the Facilitating Attuned Interactions (FAN) model (Gilkerson et al., 2012), WCSs ask caregivers a version of the “Fussy Baby Question” to elicit exploration of their own feelings of confidence and competence. When asked “What has it been like for you to parent during the pandemic?”, the emotional toll of the pandemic quickly came into focus. Caregivers described a host of complex feelings in response to their individual situations, including shock from suffering multiple losses.
Many described the loneliness of losing the social support they had relied on in the past from family, friends, mental health providers, early childhood education providers, or other families in the community. All these sources of support have critical value in strengthening feelings of parental connectedness, buffering stressors, and contributing to positive parenting practices. It is likely due to a combination of these effects that social support has also been associated with a variety of positive outcomes for children, including resiliency (Armstrong et al., 2005) and social competence (Taylor et al., 2015). For many families during the early days of the pandemic, an important safety net had been dismantled as close contact with anyone outside of their immediate household was strongly discouraged and even the most stalwart backup caregivers suddenly kept their distance.
Impact of COVID-19 on the Warm Connections Program
At the end of March 2020, Colorado WIC, supported by federal waivers from the United States Department of Agriculture, moved to a remote service delivery model in response to the pandemic. All WIC appointments with families shifted to telephone. Seemingly overnight, WIC staff transitioned to working from home, and WIC families were no longer allowed to come into the clinics except to pick up benefit cards or breast pumps. As many other organizations and programs experienced during this period of rapid transition, Warm Connections was turned upside-down. The model, created to be delivered on-site and in-person, struggled to function as intended and received fewer referrals as WIC staff focused on adapting to a remote work environment. The shift to remote WIC services impacted Warm Connections processes across the board, but most significantly affected screening and brief integrated visits—the very opportunities most likely to connect pregnant and postpartum caregivers to the program.
Focusing on Pregnant and Postpartum Caregivers
While it is generally recognized that the pandemic adversely affected the psychological health of people across the lifespan, the impact on pregnant and postpartum caregivers is pronounced. Worries unique to the perinatal period, such as COVID infection during pregnancy, premature birth, and being unable to have support persons present during labor and delivery, were frequently reported to WCSs. In addition, many caregivers expressed concern at being unable to mobilize caregiving support once home with their newborns and being separated from influential family members who would typically provide modeling and advice on newborn care.
WCS’s contact with pregnant and postpartum caregivers similarly reflected this increase in symptoms. After several months of outreach calls to caregivers in this group, serious psychological harm of persistent worry and isolation due to the pandemic emerged as a theme. Caregivers who maintained their supportive relationships appeared more likely to discuss and accept support for postpartum symptoms than caregivers who were cut off from these resources or who did not have well-developed support networks to begin with. These observations are consistent with research that identifies social support as a potentially significant protective factor in maternal mental health, with additional implications for infant development (Lebel et al., 2020).
Building Back Support
The emerging research, as well as WCSs’ anecdotal evidence regarding the increased vulnerability of pregnant and postpartum caregivers during the COVID-19 pandemic, prompted Warm Connections to pivot toward this need for support. With the buffering and protective effects of social support in mind, Warm Connections piloted a mental health outreach program specifically for postpartum caregivers in the spring of 2021. The goals of this program were (1) to provide preventive outreach and social–emotional support and (2) to enhance participants’ parenting confidence and capacity.
To balance the increased demands on WIC staff with the need for their cooperation, Warm Connections asked selected WIC staff to volunteer to pilot the new outreach program. Staff agreed to inform all caregivers seen during their first postpartum appointment that a WCS would contact them by phone within 2 to 4 business days. Participation was voluntary and would not impact their WIC status. WCS outreach calls were intentionally unstructured to allow for reflective conversations around the caregivers’ experiences, questions, and concerns. When needed, referrals were made for more intensive therapeutic services or to help with issues related to social determinants of health. Referrals emphasized continuity of care and successful connection. At the end the outreach, the WCS offered a follow-up call to lend additional support and assist with connection to referrals. Due to positive responses from participants and WIC staff, the program quickly became a fixture in the continuum of services offered by Warm Connections at the pilot clinic, and plans to expand to additional clinics are underway.
Reconnecting and Mobilizing Support—A Case Example
The following case example illustrates both the complexities and opportunities of providing supportive behavioral health intervention during the pandemic. In the initial outreach call with a first-time mom, she described feeling overjoyed to be a mother and referred to her newborn son as “a miracle.” She reported having a high-risk pregnancy and delivered her baby late preterm via emergency cesarean. She said her baby was healthy and growing each day. However, she described her own physical and emotional recovery as a slow and painful process. She disclosed feeling anxious throughout her pregnancy and mentioned feeling overwhelmed at times due to the lack of sleep and low energy. She also expressed disappointment that breastfeeding wasn’t going as expected and worry that her son wasn’t feeding enough, even though he was steadily gaining weight. While telling her story, her baby began crying in the background and she quickly ended the call but agreed to continue the conversation the following week. In the subsequent call, she revealed that this was the first time she had shared the extent of her anxiety during pregnancy with anyone. She identified having a strong support network but stated that she was fearful of having her family or friends over to help due to possible COVID exposure. Her baby once again began to cry in the background, but this time she was invited to stay on the line while she tended to him. This gave the WCS an opportunity to comment on how attentive the mother was to her son’s needs and how easily she was able to soothe him. This led to a conversation about how learning to read his cues was a source of well-deserved pride.
Throughout this consultation, it was important to normalize her feelings, especially within the context of these highly abnormal times, and to let her know that additional support was available. However, it was equally important to follow her lead in determining what would be most helpful to her and to maintain a position of empathy and wondering as she navigated this space for sharing her experiences. While she expressed some interest in learning more about online parenting groups, she felt strongly that the biggest impact would be in reconnecting with her family. With the WCS’ help, she made a tentative plan to address her fear of exposure by consulting with her doctor about how to minimize risks but acknowledged that she would still likely feel uncomfortable with close contact. She then envisioned a time when she could invite a family member over to help with child care. She identified several self-care activities she wanted to try while receiving this help (e.g., painting her nails, exercising) and became excited by the prospects. She also planned to contact the WIC clinic for free breastfeeding support, a resource she had forgotten was readily available to her. At the end of the call, she expressed feeling relieved and confident that she could chart a path forward, now and beyond COVID-19.
Though the COVID-19 pandemic continues to present unparalleled stressors, it also supports unique opportunities. Stories of connection, change, and innovation continue to surface in response to systems under stress. Warm Connections successfully pivoted service delivery in response to the pandemic, illustrating the importance of comprehensive, preventive behavioral health intervention for caregivers in the perinatal period.
The rollout of this new method of supporting caregivers addressed an initial program limitation of relying strictly on referrals for psychosocial needs, particularly in the postpartum period. An important unexpected finding is that many of the caregivers identified as high risk for PMADs by a WCS did not initially share this risk information with the WIC staff during their appointment. Such risk factors included previous history of depression and/or anxiety, perinatal complications, high levels of parenting stress, and limited social support. However, the most frequently endorsed risk factor among this group was a previous history of depression and/or anxiety, corresponding to the most robust predictor of PMADs (Rich-Edwards et al., 2006). Despite caregivers being asked about some PMADs-related risk factors by staff during WIC appointments, WIC staff are focusing on nutritional risk during the interview. Moreover, little guidance and training is provided to WIC staff on the most supportive and effective way of gathering psychosocial risk information. While Warm Connections offers training and support to staff in this area, the other demands of their job make it unrealistic to rely solely on WIC staff’s ability to triage postpartum health and mental health concerns.
Another important finding is how little support pregnant and postpartum caregivers are receiving even when PMADs symptoms are present. Only a quarter of participants who described symptoms of depression or anxiety reported they had sought support from health professionals. Further, in such cases, partners or family members were identified as the most frequent sources of support rather than a provider in a position to offer more formalized support. It is important to note that issues that arise in pregnancy and the postpartum period are common and very challenging under the best of circumstances, but when paired with the intense isolation and pressure of the pandemic, the psychological risks to the mother and to the dyad are greatly increased. This illustrates the important role Warm Connections and other community outreach organizations can play, now and in the future, by integrating novel support into already-established systems of care.
During the pandemic several parallel processes emerged between the individuals being served and the Warm Connections program. As with individual resilience, program resilience relies heavily on supportive relationships and feelings of self- and collective efficacy (Hobfoll et al., 2007). When referrals to Warm Connections from the WIC staff dropped significantly, it left WCSs in a bind of knowing the pandemic was impacting under-resourced families inequitably and that pregnant and early postpartum caregivers were among the most affected, but not having a mechanism in place to provide the support so desperately needed. This situation created a perceived lack of connection and feelings of powerlessness among the WCSs. Moreover, limited referrals led to fears for program sustainability, and morale of the whole program suffered. The innovation of this new postpartum delivery model increased caregiver social support, WCSs’ feelings of efficacy, and program outreach, thus simultaneously bolstering the resilience of participants, providers, and the program as a whole. While Warm Connections anticipates returning to an in-clinic, in-person, integrated model in 2022, the postpartum outreach started during the pandemic will continue for every WIC participant moving forward and will be expanded to other clinics.
The COVID-19 pandemic negatively affected perinatal mental health, especially among under-resourced pregnant and postpartum people. Programs that support pregnant and postpartum people have struggled to meet these burgeoning needs in environments that essentially eliminated in-person models of care. The Warm Connections program responded to this crisis by adapting its method of postpartum outreach to proactively identify and address caregiver behavioral health needs. In the process, Warm Connections discovered another useful tool (postpartum outreach) which will be incorporated into the program on a regular basis. Future practice and research should explore ways integrated behavioral health programs can better support perinatal mental health through more targeted postpartum outreach.
Perinatal Depression in Low-Income Women: A Literature Review and Innovative Screening Approach
S. Klawetter, C. McNitt, J. A. Hoffman, K. Glaze, A. Sward, and K. Frankel (2020). *Current Psychiatry Reports*
To learn more about post-doctoral and mid-career fellowship opportunities with Warm Connections, please visit https://medschool.cuanschutz.edu/psychiatry/OET/fellowships/harrisprogram/clinicaltrainingsites#ac-warm-connections-8
Ashley Sward, PsyD, IMH-E® (III-C), is an assistant professor and faculty with the Harris Program in Child Development and Infant Mental Health in the Department of Psychiatry at the University of Colorado School of Medicine. Dr. Sward is a licensed clinical psychologist and the program director for the Warm Connections Program, which serves to integrate maternal, infant, and young child mental health services into Metro-area Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics. Dr. Sward is endorsed as an Infant Mental Health-specialist and master foundations trainer through the Colorado Association of Infant Mental Health. Dr. Sward also provides trauma-specific, evidence-based therapeutic and consultative services as a provider with the Stress Trauma Research and Treatment (START) clinic. START is a premier program leading efforts in training, prevention, and treatment of stress, trauma, and adversity.
Jennifer King, LCSW, is licensed clinical social worker who received her master’s in social work at Tulane University and completed a fellowship in infant mental health at Louisiana State University in New Orleans. She has a comprehensive background in infant and early childhood mental health and perinatal mental health and has dedicated her career to serving underserved and vulnerable populations. Ms. King is currently working for Aurora Mental Health Center in partnership with the University of Colorado as a Warm Connections Specialist
Kelly Glaze, PsyD, is an assistant professor with the Harris Program in Child Development and Infant Mental Health in the Department of Psychiatry at the University of Colorado School of Medicine. Dr. Glaze is a licensed clinical psychologist and directs the Harris Expansion Community Fellowship Program, which provides a year-long, intensive training opportunity for mental health clinicians across the state of Colorado. She also acts as a supervising psychologist in the Child Health Clinic at Children’s Hospital Colorado overseeing the integrated behavioral health team. In addition, Dr. Glaze provides clinical care and reflective supervision as part of the Warm Connections Program—an innovative partnership between the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the University of Colorado that offers mental health services to underserved women, infants, and children.
Susanne Klawetter, PhD, LCSW, is an assistant professor at the Portland State University School of Social Work in Portland, Oregon. She is a maternal and child health disparities scholar, th particular interests in maternal and parent mental health and well-being. Dr. Klawetter’s recent work has focused on exploring the integration of behavioral health support for parents in novel settings including the Healthy Birth Initiatives (HBI), a culturally specific perinatal public health initiative, the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), and neonatal intensive care units (NICUs). Her research includes the exploration of the etiology of intergenerational maternal and child health disparities, intervention research to improve clinical care, and policy advocacy to address systemic drivers of disparities. She is the recipient of the Agency for Healthcare Research and Quality’s 2019–2021 Northwest Center of Excellence & K12 in Patient Centered Learning Health Systems Science. She has published on topics related to maternal and infant mental health, maternal experiences in the NICU, and parental leave policy. Dr. Klawetter is a licensed clinical social worker and instructor of clinical social work practice with more than 7 years of postgraduate interdisciplinary and clinical experience working with children, youth, and families.
Karen A. Frankel, PhD, IMH-E® (IV-C), is a professor of psychiatry and pediatrics at the University of Colorado School of Medicine. She is the director of the Harris Program in Child Development and Infant Mental Health and the Robert J. Harmon Postdoctoral Fellowship in Infant Mental Health. Dr. Frankel is a licensed clinical psychologist specializing for more than 30 years in the assessment and treatment of young children and their families. Dr. Frankel is the supervising psychologist for the University of Colorado Health Young Child Clinic. She is the executive director of the Fussy Baby Network Colorado and Warm Connections. She has a particular interest in the integration of infant and early childhood mental and behavioral health services into non-mental health, community-based settings such as primary care, home visiting, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics. Dr. Frankel has been a ZERO TO THREE national trainer for the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC0-3R) since 2004 and now for the DC:0–5.
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