Early Recognition and Prevention of Psychosocial Disorders in Children Use of the PSC in Primary Care April 8, 2010

1. Early Recognition and Prevention of Psychosocial Disorders in Children Use of the PSC in Primary Care April 8, 2010 The Child Health and Development Institute Integrating Behavioral Health and Primary Care Michael Jellinek, M.D.

2. Faculty Disclosures • In the past 12 months, I have had no financial relationships with the manufacturers of any commercial products or providers of commercial services discussed in this CME activity. • I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.

3. I. Background Increased screening & treatment are national health goals “Increase the number of persons seen in primary care who receive mental health screening and assessment”. Healthy People 2010, Objective 18-6 “Increase the proportion of children with mental health problems who receive treatment” Healthy People 2010, Objective 18-7

4. A. Identifying mental health problems in pediatrics 1960’s and 1970’s • The discovery of undetected, untreated mental health problems in adults and children • The Midtown Manhattan Study (Langer, 1965) • The “new morbidity” in pediatrics (Haggerty, et al, 1975) 1980’s • Task Force on Pediatric Education (1982) • Residency training in developmental peds (1986) • NIMH meetings on MH in primary care (1982+) • Development of PSC (1979/1984) 1990’s • Work of Costello, Burns, et al Improved identification and treatment of MH problems is recommended by: • Surgeon General’s 2001 Report on Child MH • Bright Futures (AAP & MCHB) • Healthy People 2010 Routine MH screening is required by: • EPSDT regulations

5. B. Prevalence of psychosocial problems Functioning varies over time Factors like poverty increase risk Costello, 1998

6. Dynamics for Care in the Pediatrician’s Office Risk – Poverty, LD, Single Parent, Chronic Illness, Moves & Discord Symptoms – Sub-threshold, normal variation History – Family, Mood, Substance, ADD, Losses & Stressors Development – Uneven, Delayed & Vulnerable Ages Functioning – School, Friends, Act ivies, Family, Mood/Esteem Resilience – Positive Relation with parent/adult, IQ/planner & Connectedness

7. Original use inpatient Revised for outpatient Consistent with work flow of primary care Brief Easy Cheap (free) Focus on functioning (not diagnosis) Single cut-off C. Rationale for Pediatric Symptom Checklist (PSC)

9. The Pediatric Symptom Checklist (PSC)

10. The Pediatric Symptom Checklist (PSC) continued…

11. D. History of Pediatric Symptom Checklist • Initial validation funded by NIMH in early 1990’s • Brief, parent-completed 35 item questionnaire first step that determines need for further evaluation • Increasingly used as a quality indicator • Validated for the full range of pediatric practices, and translated into more than one dozen languages including English, Spanish, Chinese, Hmong, Creole, Dutch, German, Swahili, Sanskrit • In public domain, can be used free of charge

12. PSC-35:  English  Spanish  Chinese  Japanese  Dutch  German  Hmong  Hindi  French  Haitian-Creole  Brazilian-American Portuguese  European Portuguese Somali  Pictorial PSC with English subtitles  Pictorial PSC with Spanish subtitles PSC35-Y: English Spanish French Haitian-Creole Brazilian-American Portuguese PSC-17: English Spanish Chinese PSC-32: Spanish, Chilean version E. PSC is used around the world Available Languages:

13. PSC : Japan

14. PSC: Holland

15. Spanish and English versions of Pictorial PSC

16. Kelleher et al/CBS Bernal & Estroff / Kaiser N. California Murphy et al / Ventura Public Health Murphy et al / Head Start Murphy, Jellinek, Nelson, et al /HMO Guzman et al/Chilean Public Schools Minnesota PSC projects Hacker et al/Cambridge, MA 20,000 Pediatric Outpatients 2,000 Pediatric Outpatients 6,000 Pediatric Outpatients 3,000 Head Start Students 1,500 Pediatric Outpatients 50,000+ 1st & 3rd Grade Students 10,000 Pediatric Outpatients 1,500 Pediatric Outpatients More than four dozen studies over 20 years II. Major Studies and Findings with PSC

17. More than one dozen PSC papers published over the past decade Main questions: prevalence of psychosocial problems in pediatrics, adequacy of identification, follow up, management, referral, utilization Subjects: more than 20,000 subjects, representative of all pediatric outpatient visits in the US & Canada seen in pediatric and family practice settings Methods: 55 PSC’s per practice, ratings by parents and physicians Results: 13% of pediatric patients have psychosocial problems on the PSC Only 1/2 of PSC+ patients were identified and only half of them referred Conclusions: psychosocial problems are prevalent, not adequately identified or managed, PSC a good choice as instrument for screening A. Kelleher et al/ ‘Child Behavior Study’ Nationally representative US pediatric sample

18. A. Kelleher et al/ ‘Child Behavior Study’ Utilization data; Psychosocial problems are costly Table 1. Outpatient pediatric + ER visit utilization for risk groups (N=20,080)

19. Main questions: Impact of psychosocial morbidity on utilization and costs Subjects: 1840 pediatric outpatients from 6 pediatric HMO sites Methods: Examine utilization and costs for PSC cases Results: 13% of pediatric patients have psychosocial problems on the PSC PSC+ cases have significantly more medical visits and PSC+ with internalizing problems (depression) have significantly higher costs Conclusions: psychosocial problems are prevalent and associated with higher number of medical visits and costs B. Bernal et al, 2000, ‘Kaiser HMO study’ West Coast HMO pediatric sample

20. B. Bernal et al, 2000, ‘Kaiser HMO study’ Patients with externalizing disorders higher costs

21. Main questions: feasibility of using PSC to screen for psychosocial problems to fulfill EPSDT requirements Subjects: 379 children aged 6-16 from outpatient public health clinics Methods: PSC required in 3 clinics to pilot feasibility as EPSDT MH screen PSC translated into Spanish & given orally; also used with 119 4-5 yo’s County data for billing for EPSDT MH screens examined Results: 11% of pediatric patients have psychosocial problems on the PSC Rates of MH referrals increased from 0.5% of visits to 2.9% Conclusions: use of PSC in public health settings is feasible, case rate similar to middle class practices, screening program increases referral rates C. Murphy et al, 2001, ‘California Public Health’ Ventura and San Mateo counties pediatric samples/EPSDT

22. Main questions: feasibility of using PSC to meet Head Start requirement for annual mental health screening Subjects: 663 3-5 year olds, about 2/3 of all students in a large Head Start program serving low income, primarily Hispanic families. Methods: PSC given to parents as part of annual enrollment packet; treatment provided by mental health paraprofessionals, teacher ratings, standardized test Results: 9% PSC+ and additional 11% of parents want behavioral health help for children Children with psychosocial problems significantly more likely to rated as having problems by teachers, and on standardized developmental screening test Referral and intervention rates increased Conclusions: it is possible to implement annual psychosocial screening in a large early childhood setting and to build a system of care based on parental support D. Murphy et al, 1999, ‘Head Start study’ Ventura County early childhood intervention program

23. Main questions: feasibility of PSC to screen young/older, minority/non minority, low income children for psychosocial problems; Need for services; % of unmet services Subjects: 570 2-16 year olds seen for outpatient pediatric visits in 4 Boston clinics Methods: PSC given to parents by clinic staff; positive screens referred to caseworkers from HMO who assessed overall functioning and need for services Results: 25% of children were PSC+, no differences by clinic, race, language ¾ of PSC+ school aged children were classified as SED Less than half of the SED children were receiving MH services More than ¾ of these parents stated that they wanted additional services Conclusions: possible to implement psychosocial screening in low income clinics in Mass.; large unmet need for services that can be reduced through PSC screening E. Murphy et al, 2001, ‘Boston EPSDT study’ 4 inner city outpatient pediatric clinics in Massachusetts

24. Main questions: can a program for psychosocial screening be implemented in all the low income schools in a country Subjects: 50,000+ longitudinal students thus far Methods: PSC given to parents as part first grade enrollment and again in 3rd grade; teachers also fill out standardized behavioral screen; intervention treatment provided by mental health paraprofessionals for students deemed “at risk” for conduct, depression or ADHD. Data from a standardized academic achievement test given nationally is further collected in 4th grade Results: Children in Intervention had higher academic achievement in 4th Grade The intervention worked: less likely to be at psychosocial risk after Conclusions: psychosocial problems are prevalent, not adequately managed, PSC a good choice as instrument for screening F. Guzman et al, ‘Chilean PSC study’ Psychosocial screening for first graders in Chile

25. F. Guzman et al, ‘Chilean PSC study’ • Chilean School Based Intervention – Skills for Life (SFL) • The preventive workshops are implemented during second grade. The participants in these workshops are the children with risk factors as measured by subscales of the TOCA-R and PSC administered in first grade. The 3 profiles that are the basis for the preventive activities are: • YELLOW quiet, obedient children, immature, withdrawn and with little motivation to learn. • BLUE this profile incorporates hyperactive, disobedient children, aggressive, with difficulty concentrating and paying attention and who, in addition can be immature and be unmotivated to learn. • GREEN corresponds to children who are timid, disobedient, hyperactive and aggressive.

26. F. Guzman et al, ‘Chilean PSC study’ • About 15-20% of all students are screened as being at risk in first grade. • About 50% of these children are referred to the workshops (many at risk students move or don’t follow through) • More than 90% of those referred attend the workshops regularly (defined as > 6 of the 10 student sessions). • For the intervention itself • Each referred student receives ten sessions • The parent receives three sessions • The teacher receives two sessions

27. Intervention (PHV) students do better on SIMCE F. Guzman et al, ‘Chilean PSC study’

28. F. Guzman et al, ‘Chilean PSC study’ Students with improved psychosocial scores from 1st-3rd grade do better on SIMCE in 4th grade * p < .05

29. Main questions: can routine psychosocial screening be integrated into diverse child serving settings; can referral networks be created; can electronic technologies improve can integration be increased? Subjects:300,000 pediatric outpatients, first grade students, TANF recipients 10,000 PSC Methods: Ages and Stages, ASQ SE, and PSC given to parents as part of enrollment for in more than a dozen state and county programs for 10 years Results: Positive screening rates of 5-15% depending on setting and site Referral and treatment networks established Move to electronic data where ever possible Serve diverse populations (Hmong, Somali) Conclusions: possible to weave psychosocial screening into routine care in virtually all child serving agencies, need to link agencies, coordinate care G. Minnesota Screening Projects A decade of screening pediatrics, education, & social services

30. Main questions: can routine psychosocial screening be integrated into outpatient settings; can referral networks be created; can integration be increased? Subjects: 1600 patients, students Methods: PSC and Ages and Stages and ASQ SE given to parents as part of enrollment packet for in all these systems Results: Positive screening rates of 6% PSC related to parental concern, being in counseling, Medicaid PSC+/- scores stable over 1 year Conclusions: possible to weave psychosocial screening into routine care in pediatric settings; on-site social worker able to treat most cases H. Hacker et al 2006, Cambridge Health Alliance A decade of screening pediatrics, education, & social services

31. H. Hacker et al/ ‘Child Behavior Study’ FIGURE 1 Process for pediatric screening and referral

32. EPSDT; Medicaid, US National Program 1. Rosie D lawsuit in Massachusetts Use of the PSC to Drive Quality Bright Futures Medical Home Information Using the PSC in Primary Care III. PSC – Recent Developments

33. A. EPSDT • Regulations governing well-child care for all 20 M US children on Medicaid • All well-child visits must include screening for mental health and developmental problems • If problems are found, they must be treated • States of Arizona, Massachusetts, Minnesota, Tennessee and others now recommend PSC as the screen for EPSDT • MA Chapter of AAP advocacy results in $ for screens for BCBS • Rosie D case in MA has increased pressure to screen under Medicaid/MassHealth

34. A1. Rosie D. in Massachusetts Rosie D. v. Romney: class action lawsuit re EPSDT provisions of the Medicaid Act to compel Massachusetts to: • Screen and identify children with serious emotional disturbances (PSC, A&S, MCHAT, etc) • Provide comprehensive assessments (CANS) • Provide clinical care management • Home based services including crisis services • Notify families of these benefits Website: http://massscreen.ehs.state.ma.us

35. A1. Rosie D. Approved Screening Tools

36. A1. Rosie D. in Massachusetts Nearly one half million additional screens over the past 2.5 years The figure below shows an increase from 21,081 screens in the first quarter of 2008 (just after the start of the initiative) to 63,555 in the first quarter of 2009 or a tripling of the number of screens.

37. A1. Rosie D. in Massachusetts This figure shows the sharp increase from 16.6% of all Medicaid well-child visits that have screens in the first quarter of 2008 (the start of the Rosie D regulations) to 53.6% in the first quarter of 2009 one year later. The percentage of children with an identified behavioral health risk decreased slightly over this period from 11.6 to 9.2% of those screened.

38. A1. Rosie D. in Massachusetts However, as the figure below illustrates, due to the large increase in screening, the number of children identified as at risk increased substantially from 2,445 to 5,847 between the first quarter of 2008 and the first quarter of 2009.

39. A1. Rosie D. in Massachusetts Extrapolating these figures to an annual number suggests that under the new regulations would identify about 24,000 children at risk behavioral health problems in 2008. If we accept the number of screens done in the first quarter of 2008 as an indicator of the number of children screened prior to the new regulations, then about half of these children would be newly identified as a result of the new regulations.

40. B. Use of the PSC to Drive Quality MBHP Outcomes Initiative:

41. C. Bright Futures

42. C. Bright Futures in Mental Health • Project of AAP and MCHB • A set of guidelines for health care visits including recommendations on screening • Topic-specific publications Website: http://brightfutures.aap.org/

43. D. Future Models of Primary Care Practice • Medical Home • Screening • In-house evaluation, follow-up, some treatment • Network to psychologists, urgent evaluations • Enhanced training in pediatric residency and CME • Child Psychiatric consultation and access • Integrated , inter-agency planning

44. D1. Medical Home Information A Medical Home Includes: • A partnership between families and child’s primary care clinician • A relationship based on mutual trust and respect • Connections to supports and services • Respect for cultural and religious beliefs • After hours and weekend access to medical consultation • Families who feel supported in caring for their child • Primary Care Clinician working with team of other care providers Benefits of a medical home: • Regularly see the same Primary Care Clinician and office staff who • know the family • partner in coordinating care • exchange information honestly and respectfully • Families feel supported in finding resources, for all stages of growth and development • Families who are connected to information and family support organizations • A Medical Home Partnership promotes health and quality of life as a child grows

45. Using The PSC In Your Office • Goal: For pediatric primary care clinicians to improve their recognition of which 3 to 18 year old patients have psychosocial dysfunction in a major area of their daily life at home, in school, with friends, in activities, and/or in their moods or self-esteem. • Recognition should lead to further assessment by the clinician, future follow-up to determine trajectory of dysfunction, and/or referral for more comprehensive evaluation and treatment.

46. Using the PSC in your office Context of office philosophy • Mental health • Prevention • Confidentiality How to start: 1. Decide when you want to hand out the PSC. 2. For most practices that are new to screening, the logical time would be at the start of all well-child visits. 3. Some practices screen during every visit…but the brief time allocated for sick visits may make this difficult

47. Using The PSC In Your Office 4. Some practices hand out a brief note with the PSC describing the purpose of the screening, making it clear that the screening is voluntary and like all other medical information, confidential 5. The PSC is designed to fit into the screening work flow of a primary care practice and to alert families that the pediatrician is interested in psychosocial and emotional issues. 6. Follow up PSC positives – with either MSW, RN or Pediatrician

48. Pediatrician Follow-up • The PSC is not designed to be diagnostic or to serve as a conduit to a specific treatment or medication. • Some PSC + children will already be receiving mental health services. • Discuss with the family those symptoms marked as “often”. • Alternatively, ask parents of all positively screened children several questions about each of the child’s major areas of daily functioning – family, school, friends, activities and mood to get a sense of why the number of problems reported may be so high.

49. Pediatric Assessment 1. Major areas of functioning: Family Friends Mood School Activities 2. Severity: Symptoms – Functioning – Risks – Resiliency 3. Track – Refer – Urgent

50. PSC Future 1. Pediatric entry point to a system of mental health care 2. Potential use to track functioning over time 3. Assessment of high utilizers 4. Educational implications