Marian Earls, MD Paula Duncan, MD Preventive Services Improvement Project Learning Session

1. Preventive Services Improvement ProjectImplementing Bright Futures For Early Childhood: Partnering with Parents & the Community Marian Earls, MD Paula Duncan, MD Preventive Services Improvement Project Learning Session January 21-22, 2011

2. Appleton, WI Children’s Health Ctr@ St Elizabeth Hosp Warrington, PA Kressly Pediatrics West Reading, PA All About Children Pediatric Partners PC Williston, ND ComprehensivePediatric Care Milwaukee, WI 16th Street CHC Philadelphia, PA Roxborough Peds Haverstraw, NY Haverstraw Peds Ft Washakie, WY Wind River Service Unit Brooklyn, NY Lutheran FamilyHealth Ctr 2 2 3 3 3 3 Boston, MA Children’s Hospital Primary Care Center Redwood City, CA Fair Oaks Children’s Clinic 2 2 Lorton, VA All Pediatrics 2 2 Hays, KS Hays Med Pediatric Ctr Southern Pines, NC Sandhills Peds Iowa City, IA U of Iowa Dept of Peds Charlotte, NC CMC Myers Park Pediatrics Hurst, TX Cook Children’sPhysician Network Tucson, AZSan Xavier Clinic St Louis, MO Danis Pediatrics Merritt Island, FL Atlantic Coast Pediatrics San Antonio, TX Community MedicineAssociates Thanks to our 21 PreSIP Teams!

3. What We Know Impact of experience on brain development. Growth, development, and behavior are inextricably linked. Emotional development occurs in the context of a relationship (bonding, attachment, reading cues).

4. Role of Experiencein Early Brain Development Activation of genes and gene products Interaction with genetics to determine morphological and functional brain organization Requirement for brain development to be normal Critical and sensitive periods

5. Toxic Stress • Physiological responses to stress in the infant’s environment affect the infant’s social-emotional development. • The activation of the physiologic stress response system results in increased levels of stress hormones. • Persistent elevation of cortisol, can disrupt the developing brain’s architecture in the areas of the amygdala, hippocampus, and prefrontal cortex (PFC), and therefore ultimately can impact learning, memory, and behavioral and emotional adaptation.

6. Prevalence and Risk About 16% of children have disabilities including speech and language delays, mental retardation, learning disabilities and emotional/behavioral problems. ____________ (Only 30% are detected prior to school entrance.) ____________________

7. Prevalence and Risk 13% of preschool children have mental health problems. This rate increases with the co-occurrence of other risk factors: Poverty Maternal depression Substance abuse Domestic Violence Foster care

8. Poverty Severe child hunger associated with: Increased rates of internalizing behavior problems in preschoolers and school-age children. Increased rates of anxiety and depression at school age. (U Mass Med study 2002)

9. Foster Care Children of “risky families,” who have characteristics of conflict, aggression, relationships that are neglectful. “Risky” environment disruptive of biological stress-response regulatory systems, and to psychosocial functioning.

10. Impact of Maternal Depression Infants are at risk for insecure attachment. Children with insecure attachment are more likely to have behavior problems and conduct disorder. Maternal depression in infancy is predictive of cortisol levels in preschoolers, which is linked with anxiety, social wariness and withdrawal When mothers experienced major depression, then attachment disorders, behavior problems, and depression and other mood disorders can occur in childhood and adolescence

11. Disparities Minorities receive about ½ as much outpatient mental health care as whites. Most children who need a mental health evaluation do not receive services, and Latinos and uninsured children have especially high rates of unmet needs. Limited access to mental health services for parents (often underinsured/uninsured)

12. Disparities Children in living in poverty have twice the rate of mental health problems as the general population of children. Rates of use of mental health services are extremely low among preschool children.

13. Disparities System Capacity Workforce shortage of child and adolescent psychiatrists and clinicians who can work with children. Even greater workforce shortage of child psychiatrists and psychologists who can work with very young children. Shortage of mental health providers who can treat the mother-infant dyad

14. National Perspectives onHealthy Development in Young Children AAP: new Bright Futures guidelines AAP: new priority in strategic plan-early brain development AAP: Task Force on Mental Health & COPACFH AACAP: Collaborative Mental Health Care Partnerships in Pediatric Primary Care ABCD (Assuring Better Child Health & Development) Projects: early childhood social-emotional development and mental health

15. Bright Futures, the AAP, and Health Reform Coverage of Preventive Services under section 2713 of ACA, July 19, 2010 All private health plans must cover, without cost-sharing all services described in Bright Futures: Guidelines for Health Supervision of Infants Children and Adolescents, 3rd Edition, as of Sept 23, 2010. Issues: grandfathered plans, language does not include Medicaid plans. AAP is directly advocating with Secretary Sibelius on these issues.

16. AAP: Task Force on Mental Health & Committee on the Psychosocial Aspects of Child & Family Health Chapter Action Toolkit, 2008 The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care, PEDIATRICS, 124(1), July 2009. Supplement to Pediatrics (June, 2010) Addressing Mental Health Concerns in Primary Care: A Clinicians Toolkit (July, 2010) Incorporating Perinatal and Postpartum Depression Recognition and Management into Pediatric Practice (November 2010) Addressing Social Emotional Morbidity (pending)

17. AAP Defines Medical Home Accessible Family-Centered Continuous Comprehensive Coordinated Compassionate Culturally competent

18. Medical Home also means… Caring for the whole child Considering physical, developmental and mental health together “not separating the head from the body”

19. Bright Futures Health Promotion Themes include: Promoting Family Support Promoting Child Development Promoting Mental Health Promoting Healthy Weight Promoting Healthy Nutrition Promoting Physical Activity Promoting Oral Health Promoting Healthy Sexual Development & Sexuality Promoting Safety & Injury Prevention Promoting Community Relationships & Resources

20. Bright Futures 1990: Initiated by MCHB & Medicaid NCEMCH 1995: Building Bright FuturesAAP 2003+ 1994 1996 1998 2000 2001 2002 Evaluation & State Case Studies Family Tip Sheets Anticipatory Guidance Cards BF Pocket Guide BF in Practice Mental Health & Toolkit Guidelines BF in Practice Nutrition BF II Pfizer Partnership Encounter Forms for Health Professionals and Families Encounter Forms for Families II BF in Practice Oral Health BF in Practice Physical Activity BF II Pocket Guide

21. Bright Futures Implementation 2012 2010 2004 2007 2008 2009 2011 BF Perform Prev. Serv BF VDH Web Site BF Activity Book BF Nutrition BFTI BF Pocket Guide State of WI ACA BF Periodic Survey #56 BF PreSIP BF EQIPP Module Brightening Oral Health Healthy Active Living for Families BF National Fam. Org Mtg

22. 2000 & 2002 …is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.

23. Periodicity Schedule

24. Example: 18 month old

25. Context The 18-month-old requires gentle transitions, patience, consistent limits, and respect. One minute he insists on independence; the next minute he is clinging fearfully to his parent.

26. Who has an 18 month old?

29. LANGUAGE PROMOTION/HEARING Encouragement of language, use of simple words and phrases, engagement in reading/singing/talking The development of language and communication during the early childhood years is of central importance to the child’s later growth in social, cognitive, and academic domains. Communication is built upon interaction and relationships. Health care professionals have the opportunity to educate parents about the importance of language stimulation, including singing songs, reading, and talking to their child. Parents may ask health care professionals about the effects of being raised in a bilingual home. They may be reassured that this situation permits the child to learn both languages simultaneously. ANTICIPATORY GUIDANCE Encourage your toddler’s language development by reading and singing to her, and by talking about what you both are seeing and doing together. Books do not have to be “read.” Talk about the pictures or use simple words to describe what is happening in the book. Do not be surprised if she wants to hear the same book over and over. Use simple, clear phrases to give your child instructions. SAMPLE QUESTIONS How does your child communicate what she wants? Who or what does she call by name? What gestures does she use to communicate effectively? For example, does she point to something she wants and then watch to see if you see what she’s doing? Does she wave “bye-bye”?

30. Bright Futures is the health promotion/disease prevention part of the medical home At the heart of the medical home is the relationship between the clinician and the family or youth

32. Opportunities for Prevention and Promotion in Primary Care Prenatal Visits Psychosocial and maternal depression screening Developmental & behavioral screening and surveillance in pediatric and family practice offices Social/emotional screening for children identified “at risk” Implementation requires a QI approach to office process

33. Mental Health Competencies The “primary care advantage” Longitudinal, trusting relationship Family centeredness Unique opportunities for prevention & anticipatory guidance Understanding of common social-emotional & learning issues in context of development Experience in coordinating with specialists in the care of CSHCN Familiarity with chronic care principles & practice improvement

34. Talking with Families • Identify child and parent’s strengths • Discuss developmental issues • Discuss transition stages • Share Information • Discuss community resources

35. PreSIP: Implementing Bright Futures in Early Childhood Maternal Depression Screening BMI Oral Health Developmental Screening Autism Screening Eliciting parent concerns and strengths Common factors approach Anticipatory Guidance

36. PreSIP: Practice Systems Office Systems Inventory Preventive Services Prompting System Risk Stratification Family Involvement Promoting Family’s Experience of Care Community Linkages