Integrating Behavioral Health into Pediatric Primary Care for Young Children and Families

Strategies and Lessons Learned from the FieldDeborah F. Perry, PhDDirector of ResearchGeorgetown UniversityCenter for Child and Human Development

OverviewEarly Childhood Mental HealthPolicy ContextSAMHSA-funded study methodsDescription of selected sitesLessons learnedDiscussion

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 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 PrevalenceNo 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 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 EffortsStarting Early Starting SmartEarly Head StartHealthy StepsABCDMedical Home InitiativeBright 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 HomeA 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

BITSEA, DECA-C

For Adults: 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

DECAThree 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 QuestionnaireCut down on drinkingAnnoyance with criticisms about

drinkingGuilt about drinkingEye opener: using alcohol

Lessons LearnedCo-location of services leads to better

integrationMake comprehensive screening routine

pediatric practice Mental Health for parents Substance Abuse for parents Developmental Screening tools for infants

and toddlers

Building LinkagesRelationships 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 ChallengesBilling and finances

96110, 96111Special populationsSustainability

Grant fundsMacro-level policy climate

New Tools from Bright FuturesSocial 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

How to contact me:Deborah F. Perry, PhDCenter for Child and Human Development

dfp2@georgetown.edu