Integrating Behavioral Health into Pediatric Primary Care for Young Children and Families Strategies and Lessons Learned from the Field Deborah F.
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Transcript Integrating Behavioral Health into Pediatric Primary Care for Young Children and Families Strategies and Lessons Learned from the Field Deborah F.
Integrating Behavioral Health
into Pediatric Primary Care for
Young Children and Families
Strategies and Lessons Learned
from the Field
Deborah F. Perry, PhD
Director of Research
Georgetown University
Center for Child and Human Development
Overview
Early
Childhood Mental Health
Policy Context
SAMHSA-funded study methods
Description of selected sites
Lessons learned
Discussion
The Context
Children are:
Being kicked out of child care settings
Struggling with the effects of violence
Showing the impacts of maternal
depression
Dealing with multiple family risks (parental
substance abuse, domestic violence and
mental illness)
The New Freedom
Commission
Goal
4: “Early Mental Health Screening,
Assessment and Referral to Services
Are Common Practice”
Quality screening and early intervention
in primary care offices and school-based
health centers
EPSDT is one vehicle for children and
adolescents who are Medicaid eligible to
obtain services
Social Emotional
Development
Inter-relatedness of
domains
Intimately tied to
caregivers mental
health
Core tasks:
Attachment
Behavior
Competence
Early Childhood Mental Health
The social, emotional
and behavioral wellbeing of young children
and their families
The developing
capacity to experience,
regulate, express
emotion
Form close, secure
relationships
Explore the
environment and learn
Adapted from ZERO TO THREE
Estimated Prevalence
No
national epidemiological data
Early Childhood Longitudinal Study:
10% of all kindergarten children show
problematic behavior
Rates are two to three times as high in
low-income samples
Clinical level problems are lower (410%)
Opportunities for Partnership
Well-child visits
recommended
during first three
years of life:
2-3 days, by 1st
month, 2 months, 4
months, 6 months, 9
months, 1 year, 15
months, 18 months,
2 years, 3 years.
(Medline Plus)
SAMHSA Study
Funded jointly by Center for Mental Health
Services, Center for Substance Abuse
Prevention, Center for Substance Abuse
Treatment and the Office of the Administrator
Focus on infants, toddlers and their families
Intersection between infant mental health and
primary/pediatric care
Other National Efforts
Starting
Early Starting Smart
Early Head Start
Healthy Steps
ABCD
Medical Home Initiative
Bright Futures Mental Health
Methods
Selection criteria:
Medical Home
Mental Health and
Substance Abuse
Screening
Facilitated Referrals
Developmental
Screening
Treating the Family
as the Unit of Care
Focus on pregnant women,
infants and toddlers
Protocol examined range of
constructs:
Cultural competence
Screening tools
Financing
Lessons learned
Barriers
Staff development
Multiple interviews
and/or site visits
Medical Home
A community-based primary care “medical
home” is accessible, family-centered.
continuous, comprehensive, compassionate,
developmentally appropriate coordinated,
culturally competent and accountable.
The Medical Home
Not a place
Provision of
preventive care
Anticipatory
guidance
Early intervention
Appropriate use of
sub-specialties
Interaction with
community-based
organizations:
schools, WIC, Head
Start
Maintain a central
record and data
base
24/7 coverage
Sites Selected
Beaufort Pediatrics SC
Foster Care Pediatrics,
NY
Guildford Child Health,
Inc. NC
Hagan and Rhinehart
Pediatricians, VT
Healthy Steps for Young
Children, CA
High Point Medical &
Dental Clinic, WA
Hope Street Family
Center, CA
Mary’s Center for
Maternal and Child
Care, DC
Synthesis of Strategies
Medical Home
Comprehensive
Screening
Developmental
Mental Health
Substance Abuse
Behavioral Health
Services
Facilitated Referrals
Family as Unit of
Care
Cultural
Competence
Screening Tools
For Children:
Parent’s Evaluation
of Developmental
Status (PEDS)
ASQ/ASQ:SE
Pediatric Symptom
Checklist
For Adults:
BITSEA, DECA-C
CES-D
Edinburgh Postnatal
Depression Scale
CAGE
AUDIT
2-question
depression screen
Ages & Stages: SE
Children birth thru 60 months
Series of 8 parent-completed questionnaires,
6 month intervals
10-20 minutes to complete
4-6th grade reading level
Curricular guidance for age-appropriate
activities
Developed by Jane Squires, Diane Bricker & Elizabeth
Twombly
ASQ:SE
Domains
Adaptive functioning
Autonomy
Interactions
Compliance
Coping
Self Regulation
Communication
Reliability
•
Internal consistency,
overall .82
Test-Retest (3
weeks) 94%
Validity
Sensitivity 78%
Specificity 95%
Infant Toddler Social
Emotional Assessment
ITSEA… BITSEA: 60 items based upon
empirical and clinical concerns
Children ages 12-36 months
Completed in 10 minutes by adult who knows
child well
4-6th grade reading level
49 “problem” items and 11 “competency”
items
Developed by Margaret Briggs-Gowan & Alice Carter
BITSEA
Problem Domains
Activity/Impulsivity
Aggression/Deviance
Peer aggression
Depression/Withdrawal
General Anxiety
Negative Emotionality
Maladaptive
Atypical
Competencies
Social relatedness
Imitation/Play
Empathy
Prosocial peer
Attention
Compliance
Devereaux Early Childhood
Assessment (DECA)
Strongly grounded in resilience theory:
identify within-child protective factors
Children 2-5 years old
Completed by parents or other caregivers
Assesses the frequency of 27 positive
behaviors, plus 10 item behavioral concerns
screener
DECA-C: clinically significant items
DECA
Three
domains:
Initiative:
use of independent thought or
action
Self Control: experience range of emotions
and express these appropriately
Attachment: mutual, strong, long-lasting
relationship with significant adult
Caregiver Depression
In
the past year, have you had two
weeks or more during which:
you felt sad, blue, or depressed?
Lost pleasure in things that you usually
cared about or enjoyed?
CAGE Questionnaire
Cut
down on drinking
Annoyance with criticisms about
drinking
Guilt about drinking
Eye opener: using alcohol
Lessons Learned
Co-location
of services leads to better
integration
Make comprehensive screening routine
pediatric practice
Mental
Health for parents
Substance Abuse for parents
Developmental Screening tools for infants
and toddlers
Building Linkages
Relationships
with referral sources
crucial
Philosophy,
Knowledge
approach, cultural competence
of range of services offered
Eligibility
Taking
new patients
Private/public insurance
Formal
versus informal linkages
Ongoing Challenges
Billing
and finances
96110,
96111
Special
populations
Sustainability
Grant
funds
Macro-level
policy climate
New Tools from Bright Futures
Social
In
Emotional Development
infancy (birth through 12 months)
In Early Childhood (Ages 1-4 years)
Parent-focused checklists
Domains (e.g., feeding, sleeping)
What to Expect
When to Seek Help
How to contact me:
Deborah F. Perry, PhD
Center for Child and Human Development
[email protected]