After the screen…

1. After the screen… Katherine Hobbs Knutson MD MPH Elizabeth Rihani, Manager, Child Find-Early Stages DC Learning Collaborative February 6, 2015

2. Disclosures • No relevant disclosures. • No relevant conflicts of interest. • There will be no discussion of off-label use of medications.

3. Learning Objectives • Identify screening tools and potential results. • Based on screening results, develop methods for further evaluation. • Identify when specialty referral may be indicated and community resources for referral. • Introduce treatment methods for behavioral health problems within primary care.

4. Screening tools • Edinburgh postnatal depression scale (EPDS) • Ages & Stages questionnaire – social emotional (ASQ-SE) • Strengths & Difficulties questionnaire (SDQ) • Add CRAFFT & suicide screen for teens • Patient Health Questionnaire-9 (PHQ-9)

5. 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

6. 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)

7. Negative screen • Provide anticipatory guidance for social and emotional development for the upcoming year. • Explain that screening will continue annually. • Encourage families to contact providers with social, emotional or behavioral concerns.

8. Borderline or positive results

9. Borderline or positive results • Discuss concerning sections with the family (at the current or a subsequent visit) • Clarify that the screen does not make a diagnosis

10. Borderline or positive results • Discuss concerning sections with the family (at the current or a subsequent visit) • Clarify that the screen does not make a diagnosis • Goal: Make decisions about management • Follow and reevaluate • Manage within primary care • Refer for specialty care

11. Triage decision following a borderline or positive screen

12. Triage decision following a borderline or positive screen

13. Borderline or positive results • Nature of the problem:

14. Borderline or positive results • Nature of the problem: • Developmental concerns (including autism): • Motor • Verbal • Cognitive/adaptive

15. Borderline or positive results • Nature of the problem: • Developmental concerns (including autism): • Motor • Verbal • Cognitive/adaptive • Behavioral concerns: with an ear toward… • ADHD • Anxiety • Depression • Substance abuse • Oppositional behavior

16. Triage decision following a borderline or positive screen

17. Borderline or positive results • Impact of the problem on function • Consider the impact supplement for the SDQ

18. SDQ Impact Supplement ~ Severity SDQinfo.org ~ History 1 2 ~ Impairment 1 = Borderline 2+ = Clinical

19. Borderline or positive results • Impact of the problem on function • Home • School • Peers/community

20. Borderline or positive results • Impact of the problem on function • Home • School • Peers/community

21. Borderline or positive results • Impact of the problem on function • Home: • Do caregivers feel capable of limit setting and managing behavior (special case: foster care)? • Does the family feel safe? • Does the child/teen elope? • Is there significant distress at home due to the child’s behavior? • Does the child’s behavior impact family functioning (e.g., ability to go to the store, remain employed)

22. Borderline or positive results • Impact of the problem on function • Home • School • Peers/community

23. Borderline or positive results • Impact of the problem on function • School: • Attendance. • Grades declining. • Suspensions/disciplinary measures.

24. Borderline or positive results • Impact of the problem on function • Home • School • Peers/community

25. Borderline or positive results • Impact of the problem on function • Peers/community: • Quality of friendships. • Social engagement/withdrawal (teens: texting, social media). • Legal issues.

26. Borderline or positive results • Impact of the problem on function • Home • School • Peers/community

27. Triage decision following a borderline or positive screen

28. Borderline or positive results • Safety issues • Substance abuse • Suicide • Psychosis

29. Borderline or positive results • Safety issues • Substance abuse • “Do you or your friends use drugs or alcohol?” • If yes, then clarify types of drugs, amount & frequency of use.

30. Borderline or positive results • Safety issues • Suicide • “Do you ever have thoughts about hurting yourself or sometimes wish you weren’t alive?” • If yes, then clarify • Any recent suicide attempt. • Any plan or intent for suicide attempt currently or in the recent past.

31. Borderline or positive results • Safety issues • Psychosis • “Do you ever hear voices that others don’t hear?” • If yes, then clarify if the voice(s) instruct the patient to do things – with particular attention to instructions to do anything dangerous.

32. Borderline or positive results • Safety issues • Substance abuse • Suicide • Psychosis

33. Triage decision following a borderline or positive screen

34. Borderline or positive results • Gather information about the following: • Nature of the problem • Developmental concerns • Behavioral concerns • Impact of the problem on function • Home: limit setting, dangerous/safety concerns, eloping, family distress • School: grades, attendance • Peers: quality of friendships, social engagement • Safety issues • Substance abuse • Suicide • Psychosis

35. Triage decision following a borderline or positive screen

36. Triage decision following a borderline or positive screen • Developmental concerns (including autism): • Motor • Verbal • Cognitive/adaptive

37. MakingReferralsFor children who are DC residents or who attend a DC child development center or private school District of Columbia Public Schools - Early Stages

38. Areas of Evaluation District of Columbia Public Schools - Early Stages Strong Start T: (202) 727-3665Iwww.strongstartdc.comIEarly Stages I T 202.698.8037 Iwww.earlystagesdc.org

39. District of Columbia Public Schools - Early Stages Where to Refer Birth – 2 years, 8 months • 2 years, 8 months - 5 years, 10 months Phone202-698-8037 Email referrals@earlystagesdc.org Webwww.earlystagesdc.org Phone202-727-3665 Email osse.dceip@dc.gov Web www.strongstartdc.com

40. District of Columbia Public Schools - Early Stages Determining Eligibility

41. District of Columbia Public Schools - Early Stages Disabilities Under IDEA

42. District of Columbia Public Schools - Early Stages IEP Services Special education is specially designed instruction that ensures the child’s access to the general curriculum. Related services, if determined necessary, may include: Specialized Instruction Speech/Language Therapy Physical Therapy Occupational Therapy Psychological Services Audiology Services Interpreting Services Transportation Vision Services Extended School Year (ESY) Assistive Technology Devices Medical Services School Health Services and School Nurse Services

43. Triage decision following a borderline or positive screen

44. Triage decision • Behavior concerns without impact on function or safety concerns • Consider providing guidance for caregivers & reassess in 1 month

45. Triage decision following a borderline or positive screen

46. Triage decision • Behavior concerns with impact on function

47. Triage decision • Behavior concerns with impact on function • Consider treating within primary care (ADHD, anxiety, depression, substance abuse)

50. Treatment within primary care • ADHD • Choose your favorite screening tool (Vanderbilt, SNAP, etc.). • If the child has ADHD symptoms at school and at home that started prior to age 7yo with significant impact on function, then consider treatment (meds, therapy). • Consider referral for IEP/504 at school. • Follow up within 1 month of initiating treatment.