Mental Health Screening and Assessment in Primary Care

Mental Health Screening and Assessment in Primary Care Penny Knapp MD Medical Director, Children’s Services, CA DMH, Professor Emeritus, Psychiatry & Pediatrics, UC Davis penny.knapp@dmh.ca.gov, pkknapp@ucdavis.edu Healthy Tomorrows 9/15/05 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 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  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.  Life Experience and Children’s 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 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.  The Child in Family Relationships (Primary) Parent(s) (later) Others Health CHILD Behavior Development SocialEmotional Relationships (to child) Parenting (to others) Health Mental Health PARENT Relation to Environment Work-Coping Environment Environment Environment Environment Environment Environment Environment Health Environment Environment Health Work, Coping PARENT Environment Mental Health Environment Environment CHILD Mental Health Environment Environment SocialEmotional Environment Behavior Environment Development Environment Environment Environment Environment Environment Environment 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  Risk and resilience factors Risk Child Abuse/neglect: Children’s Defense Fund estimate @ 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. Current statutory and programmatic requirements for early screening. ADA, IDEA part B and Part C  Eligibility guidelines often not linked to community diagnostic services.  WIC Job Training Housing Work, Coping DSS Health Care Title V SCHIP Medical Home CSHCN Health PARENT Mental Health Mental Health Parent-Infant Health CHILD Mental Health Environment SocialEmotional Child Care Behavior ADA, IDEA Development part C, DDS IDEA Part B ECE Special Ed President’s 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. 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. 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 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  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. 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 child’s strengths and weaknesses, present level of performance, and indicated intervention.  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.  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 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 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 Example of Screening tool: BITSEA 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 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 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 Definitions: from Screening to Intervention:ASSESSMENT     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 Definitions:DEVELOPMENTAL 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.  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 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. 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. Domains for Screening Parent mental health  Parent stress/support  Child’s development  Child’s social emotional status  Child’s physical/medical health - CSHCN  Parent-child relationship  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  Parent stress, Parent-child relationship  Parent Stress & Support: PSI (Parent Stress Index), PSI-SF (short form) Parent-child relationship: BABES Behavioral assessment of Baby’s Emotional and Social Style (Finello & Poulson 1996)  FEAS Functional Emotional Assessment Scale ASQ-SE Child Domains – examples of screening tools 1. 2. 3. Child development Child Social/Emotional Child Physical,Medical, Special Health Care Needs Denver, PEDS, BITSEA, CDR 2. ASQ-SE, TABS, DC 0-3PIR-GAS 3. AHRQ, NCQA measures 1. 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?  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. 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 AAP Mental Health Task Force Four Groups to develop Tool Kit for PCPs 1. Patient engagement 2. Clinician decision support 3. Information Systems and Tracking Support 4. Organization/Financing of Care 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 child’s developmental and socioemotional growth. The Clinical Dashboard The Dashboard lists 6 domains— cognition/language, attention/executive function, control of impulses, mood/anxiety, developmental progress, and relationships—followed by a listing of strengths, expectable functions, problems, and psychiatric diagnoses for each of the domains. 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 What to do after you screen: thresholds for treatment www.brightfutures.org/mentalhealth/ind ex.html  www.aacap.org/clinical/parameters/fullt ext/  Conners CK 1997. Conners’ rating Scales. www.mhs.co  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 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 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. Screening and Intervention for Mental Health Issues in a Pediatric Clinic Karen Hacker, MD, MPH 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  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? Pediatric Symptom Checklist Developed by Drs. Jellineck and Murphy  Validated instrument  Easy to complete  Translated into 6 languages  Pre-Implementation Pediatric 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. N=7 Incidence of positive screens annual and acute visits 7% 3% 90% PSC Positive, Not in treatment PSC Positive, In treatment PSC Negative N=100 Medical Record Review Annual Visits 100 80 60 40 20 0 N=100 Screening for Mental Health Percent 81 Mental Health Discussed Diagnosis Made Behavioral / Mental Health 19 3 Referral Challenges to Implementation Tension between child psychiatry and Pediatrics  Space  Productivity  Differences in work flow  Concerns regarding billing and registration      Annual Well Child /Adolescent Visit (5 - 19 years of age) Front desk attaches age appropriate PSC form and consent letter to patient chart PSC: 5-14 yrs. parents fill out YPSC: Older than 14 yrs. youth fill out Staff makes sure patient labels are on all three copies of PSC/YPSC Patient accepts PSC   Patient reads consent and completes PSC in waiting room. If not enough time, patient can complete form in exam room before seeing physician. Patient refuses PSC Medical assistant advises patient to hold and review PSC with pediatric provider Physician discusses PSC with patient during exam and scores PSC. Invalid if 4 or more items left blank Child 5yrs Positive screen Score >24 Child 6-16yrs Positive screen Score >28 Child >17yrs Positive screen Score >30 Patient already in counseling, but wants referral Patient not in counseling and wants referral Patient not in counseling and refuses referral Patient already in counseling, and does not want referral Patient has negative screen, but want referral (YES to #36) Patient has negative screen and does not want referral. (NO to #36) If Mental Health provider is available/on-site pediatrician introduces patient. If Mental Health provider is on-site, but in session, pediatrician page / makes appt. at front desk for patient to be seen within 2 weeks of annual visit. Mental Health Provider not on-site, provider makes appt. at front desk within 2 weeks of annual visit    Mental Health Provider: Check insurance information and obtains insurance authorization Confirm appt. with patient Update provider concerning patient via e-mail or form??????? Results of Screening Pediatric Patients Screened With PSC by Race (12/03-02/05) 5% 9% 7% 4% 46% White Black Asian Hispanic Other Unknown 30% N=1770 (Annual visits only) Pediatric Patients Screened Using PSC by Primary Language (12/03-02/05) 5% 9% 1%1% 1% 2%1% English Portuguese Haitian Creole Spanish Hindi Nepalese Korean Bengali Arabic 6% 73% N=1755 (Annual visits only) Positive & Negative Scores by Race (12/03-02/05) 50 40 30 20 10 0 White Black Hispanic Other N=1723, p=0.19 (Annual visits only) Percent 46 40 40 29 Positive Negative 5 7 8 9 4 0 Asian Those with emotional problems versus those without Percent 100 80 60 40 20 27 73 97 negative positive 3 0 Had an emotional problem N=1723, p<0.001 (Annual visits only) Did not have an emotional problem Positive Screenings by Insurance Type (12/03-02/05) Percent 100 80 60 40 20 0 Free Care/ Medicaid Private 4 58 35 37 53 Positive Negative 8 1 3 Self Ins Other N=1723, p<0.0001 (Annual visits only) Referrals No significant change in referrals to Child Psychiatry pre and post implementation  161 new referrals to mental health  Referred Patients N=161   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<.0001) 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  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.