Mental Health Screening and Assessment in Primary Care

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Mental Health Screening and Assessment in Primary
Care

• Penny Knapp MD
• Medical Director, Childrens Services, CA DMH,
  Professor Emeritus, Psychiatry Pediatrics, UC
  Davis
• penny.knapp_at_dmh.ca.gov, pkknapp_at_ucdavis.edu
• Healthy Tomorrows 9/15/05

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Workshop Goals

• Indications for screening and for assessment
• Current statutory and programmatic requirements
  for early screening.
• Risk resilience factors that influence
  services.
• Screening vs Assessment
• Examples of tools
• Activities of AAP MHTF and DPS workgroup

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Workshop Goals, continued

• Choice of screening and assessment measures.
• Basic skills needed for screenings and
  assessment
• What to do after you screen thresholds for
  treatment

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Screening more than the tool

• Use of developmental knowledge to formulate a
  more comprehensive view of the child
• Interdisciplinary issues in screening and
  assessment
• Choosing appropriate measures based on location
  of services, family literacy, language and
  culture, and primary issues.

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Life Experience and Childrens development and
mental health

• Young Children
• Early relationships are crucial
• Self-regulation underlies later reactions
• Development is experience-contingent
• School age Children Adolescents
• Relationships perpetuate or correct trajectory
• Emerging biological patterns operate
• Opportunity for selective or indicated prevention

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Indications for Mental Health Screening

• Overview of the indications for screening and for
  assessment of young children at risk for
  emotional, behavioral or relationship
  disturbances.
• Underlying this, is a concept of healthy mental
  development in young children.

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The Child in Family
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How may screening inform decisions?

• Promotion, prevention, and intervention a
  continuum
• How much risk is too much?
• What strengths assure resilience?
• Cost-benefit ratios of waiting vs. intervention

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Risk and resilience factors

• Risk
• Child Abuse/neglect Childrens Defense Fund
  estimate _at_ 1 million cases
• Prevalence rates of psychosocial diagnoses in
  preschool children 13-25
• Children with special needs/ special health
  care needs only 30 are screened.

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Current statutory and programmatic requirements
for early screening.

• ADA, IDEA part B and Part C
• Eligibility guidelines often not linked to
  community diagnostic services.

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Presidents New Freedom Commission Goal Early MH
Screening, Assessment Referral to Services are
Common Practice

• Promote the mental health of young children
• Improve and expand school mental health programs
• Screen for co-occurring mental and substance use
  disorders - link with integrated treatment
  strategies
• Screen for MH disorders in primary health care.

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Promoting the Mental Health of Young Children

• Prevalence of mental disorders in children
• 9-13 for Serious Emotional Disturbance
• 5-9 for Severe Emotional Disturbance
• Estimation prevalence in California households
  1.2, or 700,000 children
• CMHS - via compilation of studies. Populations
  and diagnoses vary. Percentages are higher in
  areas of higher poverty.

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What to screen

• Domains Development, medical factors,
  emotional/behavioral, relationship/attachment
• Condition/eligibility e.g. developmental
  delay, psychiatric disorders
• Specific risk factors e.g. social stress,
  relationship disturbance
• Possible child psychiatric disorder e.g. ADHD or
  other DBD, Mood or Anxiety disorder, Thought
  disorder

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Where to screen

• Parent screens
• Screens for a particular setting e.g. primary
  care practice, child care,
• Screens to evaluate program outcomes e.g. Head
  start, Special Needs demonstration site

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Screen for MH disorders in Primary Health Care

• The primary care provider is likely to see
  youngest children first. Older children with
  mental disorders are identified by MD or school.
• Consultation with primary care providers would
  allow better screening, prevention, and early
  intervention.

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Screening v.s. Assessment

• Screening to identify children who may need
  further evaluation to determine the existence of
  a problem (developmental, emotional, presence of
  a disability etc).
• Assessment to identify the childs strengths and
  weaknesses, present level of performance, and
  indicated intervention.

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Examples of Screening

• Newborn Screening- for inborn errors of
  metabolism, e.g. PKU, or genetic screening
• Hearing screening, vision screening
• Developmental screening - to identify
  developmental delay
• Mental Health screening - to identify the
  presence of symptoms of emotional, behavioral, or
  relationship disorder.

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Definitions from Screening to Intervention
SCREENING

• WHAT IT IS -Brief assessment procedure to
  identify children needing fuller diagnostic
  assessment
• WHO CAN DO IT- A person familiar with young
  children and with the screener.
• EFFECTIVE IMPLEMENTATION -Brief, easy to complete
• Questionnaire or interview
• High sensitivity and specificity compared to full
  assessments

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Examples of Screening tools the PEDS

• PEDS Parents Evaluations of Developmental
  Status Glascoe 1997
• Age range 0-8 years
• Respondent Parent
• Number of items 10
• Domains Learning, Development, Behavior
• Psychometrics High reliability validity
• Cross-Cultural Validity diverse standardization
  sample

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Example of Screening tool PSC

• Pediatric Symptom Checklist Jellineck, Murphy
  Burns 1986
• Age range 2-16 years
• Respondent Parent or caregiver
• Number of items 35
• Domains Behavioral, emotional problems
• Psychometrics Good. 3-pt rating scale,
  cutpoints based on age and SES risk
• Cross-Cultural Validity Eng. Spanish

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Example of Screening toolBITSEA

• Brief Infant-Toddler Social Emotional Assessment.
  Briggs-Gowan Carter 2001
• Age range 1-3 years
• Respondent Parent or caregiver
• Number of items 42
• Domains Problem, competence indices
• Psychometrics Good. 3-pt rating scale,
  cutpoints based on age and sex
• Cross-Cultural Validity Multiple languages.
  Validity established in ethnically and
  SES-diverse population

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Example of Screening tool ASQ -SE

• Ages and Stages Questionnaire Social-Emotional
  Squires, Briucker Twombly 2002
• Age range 6-60 months
• Respondent Parent or caregiver
• Number of items Age-specific, (ranging from 19
  to 33 items for 6,12,18,24,30,36,48 60 months)
• Domains Social-emotional problems, behavioral
  problems, social competencies
• Psychometrics Good. 3-pt rating scale,
  cutpoints based on age and SES risk
• Cross-Cultural Validity Eng. Spanish

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ASQ SE, continued

• Time to administer 15 minutes, limited
  psychometrics.
• Assesses 7 behavioral areas
• Self-regulation
• Compliance, Communication
• Adaptive functioning
• Autonomy, Affect
• Interaction with people
• Plus.. parental concerns

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Definitions from Screening to InterventionASSESS
MENT

• WHAT IT IS -Procedure using a standardized
  measure to answer a particular DX ? and develop
  information for RX
• WHO CAN DO IT - A professional trained in the use
  of the instrument(s) e.g.Psychologist,
  Psychiatrist,Special Education, OT, Language
  specialist
• EFFECTIVE IMPLEMENTATION - Testing should be
  directed to a specific referral question and
  results should be linked to an intervention plan.
• Child should be tested at a time when he can give
  his best performance

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DefinitionsDEVELOPMENTAL SURVEILLANCE

• WHAT IT IS -Ongoing, skilled obs. of children
  during health visits.
• WHO CAN DO IT -Trained Professional
• EFFECTIVE IMPLEMENTATION - Elicit/attend to
  parental concerns
• Collect relevant history.
• Accurate, informative observations
• Communication with other professionals.

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Definitions EARLY DETECTION

• WHAT IT IS - Identify children at risk of or with
  developing clinical problems
• WHO CAN DO IT - A person or professional familiar
  with the child
• EFFECTIVE IMPLEMENTATION - Tools include
• Screening tests
• Professional elicitation interpretation of
  parent concerns

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Definitions ANTICIPATORY GUIDANCE

• WHAT IT IS - Communicate to parent the expected
  developmental changes for the child
• WHO CAN DO IT - Trained Professional (e.g.
  Pediatrician)
• EFFECTIVE IMPLEMENTATION - Considers biomedical,
  development, behavior, family, safety and
  supported interpersonal interaction.

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Definitions Preventive Intervention

• WHAT IT IS - Early identification and
  intervention for maladaptive behaviors so as to
  prevent psychiatric disorder.
• WHO CAN DO IT - Person or professional trained to
  recognize, diagnose, and provide intervention.
• EFFECTIVE IMPLEMENTATION - Prevention may be at 3
  levels
• Universal (Primary)
• Selective (Secondary) for those at high risk
• Indicated (Tertiary) for those with clinical
  symptoms.

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Domains for Screening

• Parent mental health
• Parent stress/support
• Childs development
• Childs social emotional status
• Childs physical/medical health - CSHCN
• Parent-child relationship

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Screening for Parent Mental Health

• Parent Depression two questions
• During the past month, have you often been
  bothered by feeling down, depressed, or
  hopeless?
• During the past month, have you often been
  bothered by having little interest or pleasure in
  doing things?
• Standard screeners Edinburgh Depression Screen,
• SCID and other psychiatric measures

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Parent stress, Parent-child relationship

• Parent Stress Support
• PSI (Parent Stress Index), PSI-SF (short form)
• Parent-child relationship
• BABES Behavioral assessment of Babys Emotional
  and Social Style (Finello Poulson 1996)
• FEAS Functional Emotional Assessment Scale
• ASQ-SE

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Child Domains examples of screening tools

• Child development
• Child Social/Emotional
• Child Physical,Medical, Special Health Care Needs

• Denver, PEDS, BITSEA, CDR
• ASQ-SE, TABS,
• DC 0-3PIR-GAS
• 3. AHRQ, NCQA measures

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Technical aspects

• Reliability is test score consistent,
  dependable, repeatable?
• Validity Does test measure what it is intended
  to measure?
• Sensitivity Does test actually identify all
  at-risk children
• Specificity does test identify children who are
  not at risk?

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How good is the Screening tool?

• Highly Validated Sensitivity and specificity of
  70 or better. Ideally, sensitivity will be
  higher measure over specificity.
• Uses Developmental milestones
• Established tool has been in use for at least 2
  years and is widely distributed
• Recognized by a national organization.

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Choosing a Screener

• Parent- completed or Professional-completed tool?
• Length, Literacy level / Computer-based?
• Time required to complete and score the tool
• FOCUS
• Measures that are focused (e.g. on development or
  on mental health) and that have established
  psychometrics
• versus
• Measures that are brief and span several domains
• Cost of measure (purchase price and staff time)
  and sustainability of use
• Utility of measure for follow-up, surveillance
  and intervention

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AAP Mental Health Task Force

• Four Groups to develop Tool Kit for PCPs
• Patient engagement
• Clinician decision support
• Information Systems and Tracking Support
• Organization/Financing of Care

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Clinician Decision Support

• Issue is not which screening tool(s) but to
  assist with decision about what to do after
  screening identifies a problem.
• Clinical Dashboard concept to help pediatricians
  think about psychosocial assessment in much the
  same way they think about physical assessment.
• Not a quickie DX, but a systematic overview of
  the child for ongoing management, similar to a
  growth chart to plot the childs developmental
  and socioemotional growth.

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The Clinical Dashboard

• The Dashboard lists 6 domainscognition/language,
  attention/executive function, control of
  impulses, mood/anxiety, developmental progress,
  and relationshipsfollowed by a listing of
  strengths, expectable functions, problems, and
  psychiatric diagnoses for each of the domains.

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AAP Bright Futures Developmental Psychosocial
Screening Workgroup

• The BF Toolkit Workgroups will assist the BF
  Education Center and the Pediatric Implementation
  Project (PIP), funded by the MCHB, HRSA to,
• Review and develop implementation tools to
  complement revision of the Bright Futures
  Guidelines for Health Supervision of Infants,
  Children, and Adolescents.
• Develop selection criteria for reviewing tools,
  identifying existing tools, selecting tools based
  on criteria, and if needed, developing new tools.
• Maternal and Child Health Bureau
• Health Resources and Services Administration

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What to do after you screen thresholds for
treatment

• www.brightfutures.org/mentalhealth/index.html
• www.aacap.org/clinical/parameters/fulltext/
• Conners CK 1997. Conners rating Scales.
  www.mhs.co

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Resources

• Jellineck M, Patel FB, Froehle MC Eds 2002.
  Bright Futures in Practice Mental Health Volume
  1. Practice Guide Volume II Tool Kit.
  Arlington VA National Center for Education in
  Maternal and Child Health.
• The National Center of Medical Home Initiatives
  for Children with Special Needs
• www.medicalhomeinfo.org
• ABCD Toolkit. www.nashpd.org

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More Resources

• American Academy of Pediatrics
• http//aappolicy.aappublications.org
• National Center on Birth Defects and
  Developmental Disabilities
• http//www.cdc.gov/ncbddd/child/devtool.htm
• National Early Childhood Technical Assistance
  Center NECTAC http//www.nectac.org

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More Resources

• California Institute of Mental Health
  www.CIMH.org
• Childress AC et al 1993. The Kids eating
  Disorder survey (KEDS) A study of middle school
  students. JAACAP 32 (4)843-850
• Webster-Stratton C, Hammond M 1997. treating
  children with early-onset conduct problems A
  comparison of child and parent training
  interventions. J. Consulting and clinical
  Psychology 65 (1) 93-109.

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Screening and Intervention for Mental Health
Issues in a Pediatric Clinic

• Karen Hacker, MD, MPH

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Healthy Tomorrows Project

• Introduce screening to pediatric practice at all
  well visits for 5-19 year olds.
• Co-locate a social worker in the practice
• Track the information

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Evaluation Guiding Questions

• Did the number of children identified with mental
  health issues increase with the addition of a
  mental health screening tool compared to the
  baseline?
• Did the number of children who were referred to
  mental health services increase compared to
  baseline?
• Did children who were enrolled in the social work
  intervention show improvement in symptoms and
  school indicators as measured by PSC, absences,
  tardiness, and grades as compared to those who
  refuse?
• What was the net cost of the intervention under
  current billing and funding mechanisms?

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Pediatric Symptom Checklist

• Developed by Drs. Jellineck and Murphy
• Validated instrument
• Easy to complete
• Translated into 6 languages

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Pre-ImplementationPediatric perspective

• 43 of Pediatric providers did not feel the
  current referral system was effective
• 86 did not feel their current mental health
  screening was effective
• 72 did not feel they had adequate time to
  discuss these issues with patients
• 100 did not feel they were adequately reimbursed
  for discussion of mental health issues.

N7
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Incidence of positive screensannual and acute
visits
N100
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Medical Record ReviewAnnual Visits
N100
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Challenges to Implementation

• Tension between child psychiatry and Pediatrics
• Space
• Productivity
• Differences in work flow
• Concerns regarding billing and registration

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Results of Screening
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Pediatric Patients Screened With PSC by Race
(12/03-02/05)
N1770 (Annual visits only)
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Pediatric Patients Screened Using PSC by Primary
Language (12/03-02/05)
N1755 (Annual visits only)
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Positive Negative Scores by Race (12/03-02/05)
Percent
N1723, p0.19 (Annual visits only)
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Those with emotional problems versus those without
Percent
N1723, p 61
Positive Screenings by Insurance Type
(12/03-02/05)
Percent
N1723, p 62
Referrals

• No significant change in referrals to Child
  Psychiatry pre and post implementation
• 161 new referrals to mental health

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Referred PatientsN161

• 67 did not make an initial visit
• For those that made the initial visit (50)
• Females referred were more likely to make the
  initial visit than males (p.008)
• Those who had insurance were more likely to make
  their appointment compared to those with Medicaid
  or Free care (p.01056)
• Those with negative PSC scores were more likely
  to make their appointment compared to those with
  negative scores (p.0032)
• Whites were more likely to make it to their
  appointment than others (p

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New Challenges

• Electronic medical record
• How to incorporate a screen into the annual visit
  without overburdening the provider
• Related to ease with EMR
• Tracking to see improvement
• Provider transitions
• Increasing demand

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1 Year post implementation

• Post pediatrician survey-1.25 positive increase
  in response mean. Significant increase in those
  who felt screening was effective and efficient
• Better documentation of screening and diagnoses
• Demand for co-located social worker
• Spread to second site
• Overall increased awareness of mental health
  issues in the practice.