Alice Kuo, MD, PhD Med-Peds Rounds October 13, 2010

1. The School Function Program:A Primary Care Approach to Addressing Mental Health Problems in School-Aged Children Alice Kuo, MD, PhD Med-Peds Rounds October 13, 2010

2. Med-Peds Well-Child Care Series • School-Aged Children • Goal of K-12 is to graduate from high school and go to college or get a job • Predictors of dropout include poor academic performance, lack of engagement with school life • Mental health issues contribute to both

3. Background • Early social-emotional experiences affect brain architecture and development of young children (IOM, 2000) • 10-14% of children 0-5 years experience social-emotional problems that interfere with functioning (Egger 2006; Brauner 2006) • 21% of children and adolescents meet diagnostic criteria for a mental health disorder and have evidence of impairment (Shaffer 1996; DHHS 1999) • 16% of children and adolescents do not meet criteria for a disorder but have some impairment (Wolraich 1996) • 50% of adults with a mental health disorder had symptoms by the age of 14 years (Kessler 2005)

4. The Problem • Only 20% of children who need mental health services receive them • Why is this? • Shortage and inaccessibility of parenting programs • Shortage of specialty services • Shortage of school-based mental health services • Worse for minority populations

5. The Consequence • Vision of Pediatrics Task Force predicts that mental health care will constitute 30% or more of general pediatric practice • Primary care clinicians’ role in mental health care will differ substantially from specialists • PCCs will have to elicit psychosocial and mental health concerns from children presenting with challenging behavior, chronic somatic complaints or acute physical complaints

7. Unique Strengths of PCCs • Longitudinal, trusting and empowering therapeutic relationship with children and family members • Family-centered of medical home • Unique opportunities to prevent future mental health problems through promoting healthy lifestyles • Understanding of common social, emotional and educational problems in the context of a child’s development and environment • Experience working with specialists to coordinate care • Familiarity with chronic care principles and practice improvement methods

8. Barriers to Primary Care Change • Discomfort with knowledge and skills • Time constraints • Poor payment • Limited access to mental health consultation and referral resources • Administrative barriers in insurance plans

9. History of School Function Program at VFC • November 2005—Tuesday afternoons at MVG clinic • September 2006 social work intern rotated through • March 2007 physician assistant rotated through • February 2009—Obtained funding to hire part-time social worker • September 2009—first social work intern • January 2010—first MS3 preceptorship • July 2010—added case manager • September 2010—second social work intern • October 2010—SFP moves to Simms peds clinic • January 2011—second MS3 preceptorship

10. SFP Stats • Over 230 cases • Referrals come from pediatricians, parents, teachers, and school personnel • Developing relationships with many schools in West Los Angeles (LAUSD), SMMUSD, CCUSD, Inglewood USD (*We have communicated and worked with over 70 schools within the West LA region) • Community Partners: Westside Children’s Center, Edelman Mental Health Clinic, St. John’s Child Development Center, among others

11. Reasons for Referrals • History of school failure (46%) • Behavioral problems (46%) • Inability to do homework (38%) • Problems paying attention (36%) • Family dysfunction (12%) • Mental health issue (6%)

12. Why School Function? • Our goal is to address mild to moderate mental health issues which are hindering a child’s academic success • Mental health issues are still a stigma • Culturally, Latino parents do not seem to associate mental health issues and school performance • Latino parents are invested in their children doing well in school

13. Approach to a School-Aged Child • Don’t forget: DDS SHAVES mnemonic

14. Diet Elimination Sleep Development Home School Safety Vaccines Anticipatory Guidance Development Diet Sleep Safety Home Anticipatory Guidance Vaccines Elimination/Encopresis/ Enuresis School DDS SHAVES

15. Approach to a School-Aged Child • Don’t forget: DDS SHAVES mnemonic • BUT ask more about what is going on in school: • Not just favorite subjects, but GRADES • Friends? Loner? Bullies? • Likes or doesn’t like school? Why? • Teachers • After-school activities • Homework

16. Screening Questions for Parents • Do you have concerns about how your child is learning in school? • Do you have concerns about your child’s behavior in school? • Do you have concerns about how your child gets along with others at school? • Do you have concerns about completing homework? • Has teacher expressed concerns about your child? • Is your child at risk for repeating school year? • Is your child getting D’s and/or F’s? • Does your child have 2 or more C’s? **If “yes” to any of the above, consider referral to SFP

17. Referring Patients into SFP • Complete SFP Referral Form • Ask parents to sign “SFP Release of Information” • Give Vanderbilts if applicable • Request a follow-up SFP appointment in 2-3 weeks

18. School Function Program Social Work SFP Screener Initial Contact (Positive SFP Screen): * Complete SFP referral form for SFP Clinic Slot * Social Work/case management will engage family: - Introduction to SFP services - General Intake of school problem - Psychoeducation & Community Resources - Plan for follow-up - Summary to referring physician Forms to be completed: * SFP referral form * Release of information * Vanderbilt if applicable * Schedule return visit to SFP Clinic (2 weeks) Initial Contact for general psychosocial issues : * Social Work/case management will engage family: - Introduction to VFC & community services - Brief assessment (Anxiety, Depression, Behavioral & Social) - Psychoeducation - Referral information - Summary of plan with referring physician • Referral to community mental health: • Venice Family Clinic 3rd floor mental health & social services • Saint John’s Child & Family Development Center • Didi-Hirsch Mental Health Counseling Center • Family Services & Vista Del Mar • Edelman Los Angeles County Mental Health • School based mental health • SFP Clinic Visit SFP: • Case consult with SFP social work • * SFP Physician Intake & Diagnostic • Differential • * Review of clinical documents & information: • Vanderbilts, IEP, Evaluations, School • Records Reports & Observations • * School consultation if needed. • * Psychoeducation regarding Diagnosis & • Intervention Plan Standard follow-up by pediatric physician at VFC. SFP 2 month follow –up & continued case management.

19. SFP visits at Simms • Starting October 1, two slots per afternoon for #349 (M, Th, F) have been converted to SFP slots; staffed by residents, extra time allowed • On Mon PM, social work intern will be available to provide support • On Th, F PM, case manager will be available to provide support (can be there in Med-Peds on Fridays) • For Tuesday clinic, make the referrals and have forms filled out and Sandra will pick up the referrals on Thursday

20. SFP Clinic Visit • SFP residents will be synthesize information from SFP social work intern or case manager • Differential diagnosis for academic difficulties • Developmental disability/mental retardation • Learning disorder/disabilities • Attentional issues • Mental health issues • Family dysfunction • SFP residents will contribute medical aspects which may affecting academic performance • Together, SFP residents and SFP social work intern/case manager will come up with action plan (next steps)

21. SFP Screener SFP Clinic Intake or Follow-Up Developmental * PDD * Autism * Aspersers * Delayed Milestones ADHD/ADD * Inattentive subtype * Hyperactive/Impulsive Subtype * ADHD Combined Learning Disability * Dyslexia * Dysgraphia * Dyspraxia * Auditory and/or Visual Processing Disorder * Dyscalculia Psych * Anxiety * Depression * Behavioral * Oppositional Defiant * Family Psych Issues Social * Child Abuse * Domestic Violence * Financial * Family Stressors Intervention Westside Regional Ctr Special Education? IEP/ School Eval? Home visit Parent education Case Management Intervention Vanderbilts (2x) Direct Observation Teacher/School Report IEP/School Eval? Home Visit Rx Case Management Intervention Westside Regional Ctr IEP/School Eval Special Education? Accommodations Home visit Parent education Teacher /School Report Case Management Intervention 3rd floor referral Community Mental Health School Therapy Services DCFS SFP: Brief Tx (5 sessions) Parent Education

22. Case Clarence is 2 years 3 months and does not speak. In addition, Mom reports that he has behavioral problems such as head banging and holding the saliva in his mouth until he drools. He tends to play by himself rather than with other children or even his 5 year old brother.

23. Autism Spectrum Disorder • 2007 CDC MMWR report stated that the prevalence of autism was 1:150 and 1:90 boys • 2009 NSCH study reports 1:90 (1% of U.S. children) and 1:50 boys • 10-25% of children “lose” their ASD diagnosis • Some studies suggest that the “epidemic” of autism could be influenced by broadening of diagnostic criteria

24. Diagnosis of Autism Delays or abnormal functioning in one of the following three areas, with onset of symptoms prior to age 3 years A. social interaction B. language as used in social communication C. symbolic or imaginative play

25. Regional Center • 1977: Lanterman Developmental Disabilities Act • California Department of Developmental Services (DDS) contracts with 21 Regional Centers (private, non-profit) • IFSP, ITP

26. Case Her parents bring 8-year-old Maya to you in clinic for well-child visit. When asked about school, her parents state that Maya makes average grades in second grade and behaves well in class, although her teachers state that she is a bit of a “daydreamer.” When you give her the book and ask her to read a page, you realize that she struggles to sound out words. Her parents state that she still cannot read and needs their help to complete homework.

27. ADHD DSM-IV criteria • 6 out of 9 possible symptoms of inattention • 6 out of 9 possible symptoms of hyperactivity/impulsivity • Some symptoms present before age 7 years • Impairment from symptoms present in 2 or more settings • Clear evidence of clinically significant impairment in social, school or work functioning • Symptoms not due to PDD, schizophrenia or other psychotic disorder

28. NICHQ Vanderbilt Parent and Teacher Assessment Scales • Developed specifically to screen for DSM criteria • Scoring is relatively straightforward • This is meant to be additional information to help pediatricians make a diagnosis; not meant to replace clinical judgment

29. Stimulant Medications • Most studied medication in pediatric population • Relatively safe with predictable side effects • Difficulty sleeping; insomnia • Decreased appetite; weight loss • Vague abdominal symptoms • Short-acting, may use longer acting or repeat dosing • Only needed as long as child needs to concentrate or focus; drug holidays • Not necessarily forever; could be only as long as until child is able to manage inattention behaviorally

30. Case • Jimmy is an 8 year old in 3rd grade at Main Avenue Elementary School. He made B’s and C’s in 1st and 2nd grade, but for the first semester of 3rd grade has made D’s and F’s. At the parent-teacher conference, his teacher informs his parents that he is not completing his homework and is unable to answer questions on tests. What more information do you want to know and what do you think might be going on?

31. What is a “Learning Disability”? • 1960s: “minimal brain dysfunction” • 1963: Association for Children with Learning Disabilities • 1969: federal legislation • 1975: US Public Law 94-142, Education for all Handicapped Children “least restrictive environment”; 40% federal funding commitment

32. IDEA, 2004 • Individuals with Disabilities Education Act (PL 108-446) • Part A General Provisions • Part B (3-21 years); free and appropriate public education • Part C (0-3 years); early intervention services • Part D National Activities

33. IDEA, 2004 • More than 6 million children receive special education under IDEA (2009) • 44% of these are for “learning disabilities” • 11.5% (1991) to 13.5% (2005) in U.S. • Peaked at 10.6% in 1999 in California and has since declined slightly to 10.4% (2007)

34. Special Education • Amount spent per non-disabled child in public school $7,000/year • Amount spent per child in special education $23,000/year • Federal mandate with no fiscal backing—6-15%, not 40% • Of $9.3 billion spent on special education in California in 2007, very little comes from federal government; shift of burden from state to local districts

35. IEP:Individualized Education Plan • Cornerstone of Special Education Law • Developed by special educator/school psychologist, child’s teacher, and child’s parent(s) • Includes following 3 components: • Child’s eligibility for special education • Programs to be provided • Criteria to evaluate progress

36. IEP:Individualized Education Plan • California timeline (law) • School has 15 days to provide parents with plan for assessments after written request received • Parents have 15 days to approve assessment plan • School has 50 days to complete assessment and hold IEP meeting

37. Regular classroom Special education teacher consults Team teaching, teacher’s aide Resource room Remedial instruction Tutorial instruction Special skills Pull-out class Join regular ed students for lunch and P.E. Special schools Day programs Residential programs Types of Special Education

38. Case Lisbeth is a 16-year-old in high school whose mother brings her to the clinic. The mother reports that Lisbeth won’t do her homework, that she spends all day on the phone with her friends, and this year she went from being an A’s and B’s student to a D student. Lisbeth appears angry and won’t answer your questions in the clinic, even when you ask her mother to leave the room.

39. Mental Health in Schools • AB 3632 (1984): entitlement to mental health service for school children with serious emotional disturbances • Specifies that therapy treatment services be provided by the Department of Mental Health in the public schools and be exempt from financial eligibility standards and family repayment requirements

40. Case Justin is a 15-year-old who has ADHD and severe emotional disturbance. He has been in special education since 3rd grade. The schools want to send him away to a residential program and Mom wants him to live at home and attend a day treatment program. She is appealing to you as her pediatrician to help them.

41. Case • Annie is a 10-year old girl in fifth grade with type 1 diabetes. She is an average student but struggles with math. Her mom reports that she goes to the resource room twice a week for special math tutoring. You astutely ask about Annie’s IEP, and Mom has no idea what you’re talking about. What’s going on?

42. Section 504 of the Rehabilitation Act • Accommodations must be made for individuals with disabilities in institutions that receive federal funds—civil rights violation • Parents have no legal rights to assessments, contest treatment plan, or fair hearing

43. Conclusions • School Function at Simms = social justice • K-12 is not on a curve; our patients should be expected to make A’s and B’s • Being bilingual is not a reason to repeat a grade • Academic success is a prerequisite for breaking the cycle of poverty • “The metric of success for pediatricians should be the high school graduation rate of their patients”—Bob Brook