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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

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Integrating behavioral health into pediatric primary care for young children and families l.jpg

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 l.jpg
Overview for Young Children and Families

  • Early Childhood Mental Health

  • Policy Context

  • SAMHSA-funded study methods

  • Description of selected sites

  • Lessons learned

  • Discussion


The context l.jpg
The Context for Young Children and Families

  • 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)


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The New Freedom Commission for Young Children and Families

  • 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


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Social Emotional Development for Young Children and Families

  • Inter-relatedness of domains

  • Intimately tied to caregivers mental health

  • Core tasks:

    • Attachment

    • Behavior

    • Competence


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Early Childhood Mental Health for Young Children and Families

  • The social, emotional and behavioral well-being 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


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Estimated Prevalence for Young Children and Families

  • 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 (4-10%)


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Opportunities for Partnership for Young Children and Families

  • 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)


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SAMHSA Study for Young Children and Families

  • 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


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Other National Efforts for Young Children and Families

  • Starting Early Starting Smart

  • Early Head Start

  • Healthy Steps

  • ABCD

  • Medical Home Initiative

  • Bright Futures Mental Health


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Selection criteria: for Young Children and Families

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

Methods


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Medical Home for Young Children and Families

A community-based primary care “medical home” is accessible, family-centered. continuous, comprehensive, compassionate, developmentally appropriate coordinated, culturally competent and accountable.


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Not a place for Young Children and Families

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

The Medical Home


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Beaufort Pediatrics SC for Young Children and Families

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

Sites Selected


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Medical Home for Young Children and Families

Comprehensive Screening

Developmental

Mental Health

Substance Abuse

Behavioral Health Services

Facilitated Referrals

Family as Unit of Care

Cultural Competence

Synthesis of Strategies


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For Children: for Young Children and Families

Parent’s Evaluation of Developmental Status (PEDS)

ASQ/ASQ:SE

Pediatric Symptom Checklist

BITSEA, DECA-C

For Adults:

CES-D

Edinburgh Postnatal Depression Scale

CAGE

AUDIT

2-question depression screen

Screening Tools


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Ages & Stages: SE for Young Children and Families

  • 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


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Domains for Young Children and Families

Adaptive functioning

Autonomy

Interactions

Compliance

Coping

Self Regulation

Communication

Reliability

Internal consistency, overall .82

Test-Retest (3 weeks) 94%

Validity

Sensitivity 78%

Specificity 95%

ASQ:SE


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Infant Toddler Social Emotional Assessment for Young Children and Families

  • 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


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Problem Domains for Young Children and Families

Activity/Impulsivity

Aggression/Deviance

Peer aggression

Depression/Withdrawal

General Anxiety

Negative Emotionality

Maladaptive

Atypical

Competencies

Social relatedness

Imitation/Play

Empathy

Prosocial peer

Attention

Compliance

BITSEA


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Devereaux Early Childhood Assessment (DECA) for Young Children and Families

  • 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


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DECA for Young Children and Families

  • 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


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Caregiver Depression for Young Children and Families

  • 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?


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CAGE Questionnaire for Young Children and Families

  • Cut down on drinking

  • Annoyance with criticisms about drinking

  • Guilt about drinking

  • Eye opener: using alcohol


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Lessons Learned for Young Children and Families

  • 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


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Building Linkages for Young Children and Families

  • Relationships with referral sources crucial

    • Philosophy, approach, cultural competence

  • Knowledge of range of services offered

    • Eligibility

    • Taking new patients

    • Private/public insurance

  • Formal versus informal linkages


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Ongoing Challenges for Young Children and Families

  • Billing and finances

    • 96110, 96111

  • Special populations

  • Sustainability

    • Grant funds

  • Macro-level policy climate


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New Tools from Bright Futures for Young Children and Families

  • Social Emotional Development

    • In 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


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How to contact me: for Young Children and FamiliesDeborah F. Perry, PhDCenter for Child and Human Development

[email protected]


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