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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

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
Overview
  • Early Childhood Mental Health
  • Policy Context
  • SAMHSA-funded study methods
  • Description of selected sites
  • Lessons learned
  • Discussion
the context
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
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
Social Emotional Development
  • Inter-relatedness of domains
  • Intimately tied to caregivers mental health
  • Core tasks:
    • Attachment
    • Behavior
    • Competence
early childhood mental health
Early Childhood Mental Health
  • 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

estimated prevalence
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 (4-10%)
opportunities for partnership
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
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
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

Methods
medical home
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

The Medical Home
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

Sites Selected
synthesis of strategies
Medical Home

Comprehensive Screening

Developmental

Mental Health

Substance Abuse

Behavioral Health Services

Facilitated Referrals

Family as Unit of Care

Cultural Competence

Synthesis of Strategies
screening tools
For Children:

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
ages stages se
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%

ASQ:SE
infant toddler social emotional assessment
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

BITSEA
devereaux early childhood assessment deca
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
slide22
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
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
CAGE Questionnaire
  • Cut down on drinking
  • Annoyance with criticisms about drinking
  • Guilt about drinking
  • Eye opener: using alcohol
lessons learned
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
Building Linkages
  • 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
ongoing challenges
Ongoing Challenges
  • Billing and finances
    • 96110, 96111
  • Special populations
  • Sustainability
    • Grant funds
  • Macro-level policy climate
new tools from bright futures
New Tools from Bright Futures
  • 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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