Mental Health Screening in Pediatric Primary Care

1. Mental Health Screening in Pediatric Primary Care Lee Beers, MD (Children’s National Medical Center) Matthew Biel, MD, MSc (Georgetown University Hospital)

2. WELCOME! Funded by a contract from DC Department of Health Endorsed by the DC Department of Health Care Finance and DC Department of Behavioral Health 153 providers enrolled (22 new) 16 practices enrolled (5 new) Monthly chart reviews and team meetings…stay tuned for details CME/MOC credit

3. Disclosures • We have no relevant disclosures • We have no relevant conflicts of interest • There will be no discussion of off-label use of medications

4. Learning Objectives • Describe the purpose of routine mental health screening in pediatric primarycare • Introduce the screening tools approved by the DC Department of Behavioral Health for use in pediatric primarycare • Explore strategies to engage families around mental health screening in the primary care setting

5. Improving Mental Health Screening in Pediatric Practice: A QI-MOC Learning CollaborativeWhy are we doing this? Why now? • Mental health concerns are common • Pediatric primary care providers are on the front lines • Surveillance (required) vs. Screening (recommended) • DC Medicaid MCO contracts….

6. Things you may be worrying about… • I can’t do this on my own! • We will help walk you through it! • It’s a team approach • I’m not sure what to do with a “positive” screen • Learning sessions • DC Resource Guide • Mental Health Coach • I struggle to access MH services for my patients! • A real problem– we will update you on available resources • Coming soon…DC Mental Health Access in Pediatrics Program (DC MAP) • A phone consultation program for pediatric primary care providers

7. Why is this training important for your patients? • Behavioral and emotional difficulties are COMMON • Approximately 20% of children have a mental health problem at any given time • Approximately 10% have significant impairment • Over one third of children followed for three to seven years cumulatively qualified for a psychiatric diagnosis • Even higher percentages in low SES populations

8. Why is this training important for your patients? • Behavioral and emotional difficulties are IMPARING • Major impact upon school performance, social development, family functioning, physical health, and risk-taking behaviors • Unrecognized & untreated MH problems in childhood  more severe & persistent mental health problems in adolescence and adulthood • Not just a stage for many kids– problems persist and recur • These are among the most disabling and expensive health conditions across the lifespan

9. Why is this training important for your patients? • Behavioral and emotional difficulties are TREATABLE • Evidence-based, practical, and acceptable treatments exist for a wide range of childhood MH problems • YET-- the majority of children with emotional and behavioral disturbances receive inadequate mental health care

10. Why primary care? Primary Care is often seen as the first stop by families to get help with MH issues Stigma associated with seeking specialty MH treatment Workforce shortage of pediatric MH professionals One child psychiatrist for every 10,000 kids requiring MH treatment Viewed by AAP as a key function for pediatric primary care Medical home model includes assessment and treatment for MH problems by the PCP

11. Challenges and obstacles Time: how to fit it in among the other demands of the 15-min visit? Money: what about reimbursement for time spent? Knowledge and comfort: limited training in mental health in pediatrics and family practice residency programs

12. Now for a few more challenges and obstacles Families and youth may struggle to put concerns into words Cultural/ethnic variation in comfort and ease in reporting issues Stigma, shame Treatment depends on active parent and youth involvement Require trust and partnership between provider and family to Decide upon intervention Chart progress

13. Now for the good news… • Most pediatric providers are already doing lots of MH work • Most pediatric providers excel at partnering with families • Identification of MH issues as a concern is a hugely important step • Reduces stigma • Empowers families to seek help • Creates hope for change

14. Why use screening tools? • Problems are easy to miss • Pediatricians identified only 20% of children with MH problems using only their clinical impressions • Only 30-40% of parents volunteer concerns without prompting • Screening may: • Help family recognize that this is an area for discussion • Point toward an area of diagnosis • Give an indication of severity • Screening tools identify broadcategories of concern (anxiety, mood, attention), but are not diagnostic

15. Preparing Families for Screening

16. Setting the stage for screening • Before providing the screen, prepare parents and youth in advance. • Pamphlets or videos in the waiting area and exam rooms to expose parents to the concept of behavioral-health screening • Clarify what screening means: not a diagnosis • It is natural for families to feel apprehensive around MH discussions • Apprehension eases when the screening process is explained • How medical staff approaches topic of MH with a family can impact family’s understanding of and participation in interventions • Use the idea of a partnership, conveying respect for the parents as an expert on the child and continually seeking their perspective on the child and the situation

17. Discussion of a positive screen • Verbally acknowledge the screen and explain the score and the concerns indicated • Decide how much time remains in that visit • consider a return visit or telephone follow-up if time is inadequate • Referring immediately to a mental health provider may be appropriate for patients with additional evidence of significant mental/behavioral concerns, such as a parental concern or clinical interaction with the youth • Always inform parents and youth that the screen does not make a diagnosis • Use the screen responses to ask some more focused, open-ended questions • “It seems you are seeing some behavioral challenges with your child. Can you tell me more?” • “It seems like you’ve been having lots of sad feelings. I’d like to hear about what’s going on.”

18. Discussion of a negative screen • If the results of the screen are reassuring (“negative”) • Acknowledge as such to the parent/guardian and youth • “Things seem to be going well-- that’s terrific.” • Ask if any questions came up while the form was being completed • This can help to build the provider-patient relationship • More likely to come to you if mental health issues emerge in the future • Don’t forget to document and bill for screening • CPT code 96110 (TS modifier for at risk screens)

19. Dept of Behavioral Health-approved tools • EPDS, ASQ:SE, SDQ*, PHQ-9, (*Recommend that providers supplement with brief suicide and substance use screening for adolescents) • What are the valid age ranges for each? • What information can the tool provide? • What is the time commitment (to complete and to score) for each? • In what other languages are these tools available? • How does practice access recommended screening tools?

20. Edinburgh Postnatal Depression Scale • What is it? • Brief screen for postpartum depression • What domains does it cover? • Depression and anxiety • Who to screen using this scale? • Mothers in the first year postpartum • What is the time commitment to screen and score? • Self-administered in less than 5min; score in less than 2min • Available in 20 languages, freely available in English at: http://www2.aap.org/sections/scan/practicingsafety/toolkit_resources/module2/epds.pdfCan provide in other languages to practices that implement.

21. Ages and Stages Questionnaire– Social Emotional (ASQ-SE) • What is it? • Parent-completed to screen young children for social or emotional difficulties. • Which domains does it cover? • Self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people. • What are the valid age ranges? • 3-66 months with eight age-appropriate versions for use at 6, 12, 18, 24, 30, 36, 48, and 60 mos • What is the time commitment to complete and to score? • 30 questions-- each questionnaire takes 10–15 min for parents to complete and 2–3 min to score • Available in English and Spanish; must be purchased: agesandstages.com • Will be purchased for all participants in Learning Collaborative

22. Strengths and Difficulties Questionnaire (SDQ) • What is it? • Brief behavioral health screening questionnaire for youth • Which domains does it cover? • Emotional problems, conduct problems, attention/hyperactivity problems, peer problems, and prosocial attributes • What are the valid age ranges for each? • 2-16 years old (though adult version available for youths 17-21 years old) • Parent and teachers complete for ages 2-16, youth version for ages 11-21 • What is the time commitment to complete and to score? • 25 questions– approximately 10 min for teachers/parents/youth to complete; approximately 2 min to score by hand • Available in 77 languages; free @ sdqinfo.org (< 16 years) and sdqinfo.org/adult (> 17 years); free scoring @ sdqscore.org

23. Patient Health Questionnaire(PHQ-9) • What is it? • Brief depression screening for adults • What domains does it cover? • Core symptoms of depression • What are the valid age ranges? • Ages 18 and up • What is the time commitment to complete and to score? • Nine questions– less than five minutes to complete, about one minute to score by hand • Available in 48 languages; free download @ phqscreeners.com

24. What about screening for suicide in patients<18yo? • Every patient ages 12 and up should be screened for suicide risk • NOT CONTAGIOUS– THES QUESTIONS DO NOT PLACE IDEAS IN KIDS’ HEADS • “In the past few weeks, have you wished you weren’t alive anymore?” • “In the past few weeks, have you thought that you or your family would be better off if you were dead?” • “In the past few weeks, have you thought about suicide?” • “Have you ever tried to hurt yourself or to commit suicide?”

25. What about screening for adolescent substance use?CRAFFT Screen for Substance Abuse • What is it? • Brief screen for adolescent substance abuse • What domains does it cover? • High risk alcohol and drug use • What are the valid age ranges? • Validated in ages 14-18yo, commonly used in patients 10-21yo • What is the time commitment to screen and score? • Self-administered or clinician-administered; 2 min to complete, 1 min to score • Freely available in 13 languages @ http://www.ceasar-boston.org/CRAFFT/index.php

26. 10 Steps to Implementation Pre-work….much of this we have done for you! • Identify a leader and champions—a multi-disciplinary team approach works best • Consider the special needs of your patients—ask them what they want • Map out a workflow (knowing it may change…)—include documentation and billing • Identify your resources • Train the practice team—not just providers • Identify groups who need more in-depth trainings

27. 10 Steps to Implementation • Identify your community partners • Review your data regularly • Train, and train again • Consider incentives A final thought….none of us will get this right the first time. Take advantage of your peers for support and ideas. Other practices in DC are doing this, and doing it well—so can you!

28. Getting ready—First steps…AAP Practice Readiness Inventory • All participants will receive AAP Mental Health Toolkit • We will send MH Practice Readiness Inventory to you electronically • Located in QI teamspace • Complete together as a team • Identify areas for improvement and create an action plan

29. Questions? • Lee Beers, MD (lbeers@childrensnational.org) • Matthew Biel, MD, MSc (mgb33@georgetown.edu)