Bright Futures in Practice: Mental Health - LouisianaChildren.org

The Role of the Primary Care Pediatrician in the Prevention and Recognition of Maltreatment and Psychosocial Disorders in Children Louisiana Child Well-Being Summit April 16, 2014 Michael Jellinek, M.D.

Faculty Disclosures

1. 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. 2. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.

Background Increased screening & treatment are national health goals “Increase the proportion of primary care physicians who screen youth aged 12 to 18 years for depression during office visits.” Healthy People 2020, MHMD Objective 11.2

“Increase the proportion of children with mental health problems who receive treatment.” Healthy People 2020, MHMD Objective 6

Identifying mental health problems in pediatrics 1960s and 1970s •

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) 1980s •

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)

1990s •

Work of Costello, Burns, et al

Improved identification and treatment of mental health problems is recommended by: •

Surgeon General’s 2001 Report on Child MH

•

Bright Futures (AAP & MCHB)

•

Healthy People 2020

Routine mental health screening is required by: •

EPSDT regulations

Prevalence of psychosocial problems Functioning varies over time Factors like poverty increase risk

5% 25%

Costello, 1998 70%

High Need (SED [Both Dx + Impr]) Low Need (Neither Dx or Imprmt)

Moderate Need (Either Dx or Impr)

Current Burdens and Realities

1. Economics of pediatric primary care (current Fee for Service, future Global Budget?)

2. Tempo of Practice, scheduling 3.

Residency training priorities versus current needs and expectations

4.

Availability of referral services and expertise

Major Opportunities

1. Post-Partum and Maternal Depression – Screen for symptoms verbally or by questionairre, (Edinburgh Postnatal Depression Scale, PHQ 9 in handout materials) Family History of depression 2. Violence in the Home – History of parent being abused as child, violence between spouses, previous child abuse or neglect, substance use.

Poverty as a stressor, double rates of disorder 3.

Clinical Implications – maltreatment, cognitive, violence

Relevant Support Services to Primary Care

1. Parent Help – Substances, Depression, Violence 2.

Child Help – Temperament, ADHD, Behavior

3. Home Visiting Services 4.

Early Child Care/ Head Start

5.

Interagency tensions and need to simplify and cooperate

Major Opportunities Continued

4. Parental Discord – Annual question on “How well are family members getting along?” 5. Adolescent Issues: Maltreatment

Substance use - CRAFFT Depression – PHQ 9 School Drop-out/graduation

Biopsychosocial Dynamics in Pediatric Primary Care Risk – Poverty, LD, Single Parent, Chronic Illness, Moves & Discord

Sx – Active (abuse), Sub-threshold, nl .variation

Development – Uneven, Delayed & Vulnerable Ages

History – Family, Mood, Substance, ADD, Losses & Stressors

Functioning – School, Friends, Act ivies, Family, Mood/Esteem Resilience – Positive Relation with parent/adult, IQ/planner & Connectedness

Rationale for Pediatric Symptom Checklist (PSC) • Need for 4 to 16 y.o process to recognize “the blue fish” • Consistent with workflow of primary care • Brief

• Easy • Cheap (free) • Focus on functioning (not diagnosis) • Single cut-off , Subscales of interest

• National Quality Forum Endorsed (!)

The Pediatric Symptom Checklist (PSC)

The Pediatric Symptom Checklist (PSC) continued…

PSC http://www.massgeneral.org/psychiatry/services/psc_home.aspx AVAILABLE LANGUAGES PSC-35

♣ Chinese ♣ Hindi

PSC-35-Y

♣ English

♣ Haitian-Creole ♣ Setswana

♣ Dutch

♣ Hmong

♣ French

♣ English

♣ Italian

♣ Filipino

♣ Japanese

♣ Brazilian-American ♣ Spanish Portuguese

♣ French

♣ Khmer

♣ German ♣ Malayalam ♣ Haitian-Creole

♣ Setswana

♣ Hebrew

♣ Somali

PSC-17 ♣ Chinese ♣ English

♣ Brazilian-American Portuguese ♣ European Portuguese

♣ Spanish ♣ Vietnamese PSC-17-Y

♣ English

♣ Spanish

♣ Pictorial PSC with English subtitles ♣ Pictorial PSC with Filipino subtitles

♣ Pictorial PSC with Spanish subtitles

PSC-33

♣ Spanish, Chilean version

PSC : Japan

PSC: Holland

Spanish, English, and Filipino versions of Pictorial PSC

Major Studies and Findings with PSC More than 100 studies over 25 years A. Kelleher et al/CBS

•

20,000 Pediatric Outpatients

B. Bernal & Estroff/Kaiser N. California

•


C. Murphy et al/Ventura Public Health

•


D. Murphy et al/Head Start

•

3,000 Head Start Students

E. Murphy, Jellinek, Nelson, et al/HMO

•


F. Guzman et al/Chilean Public Schools

•

50,000+ 1st & 3rd Grade Students

G. Minnesota PSC projects

•


H. Kuhlthau et al/Massachusetts Medicaid

•

590,000 Well Child Visits

A. Kelleher et al: ‘Child Behavior Study’ Nationally representative US pediatric sample •

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 primary care settings in the US & Canada and clinician judgment

• Results: – 13% of pediatric patients have psychosocial problems on the PSC

– Only half of PSC+ patients were identified and only half of them were referred • Conclusions: Psychosocial problems are prevalent but neither adequately identified nor managed; PSC a good choice as instrument for screening

A. Kelleher et al: ‘Child Behavior Study’ Utilization data; Psychosocial problems are costly Table. Outpatient pediatric + ED visit utilization for risk groups (N=20,080) % of sample

Mean # visits (SD)

p value

Good or very good

96.3%

2.19 (2.74)

.0001

Fair or poor

3.7%

5.23 (5.29)

PSC negative

87.3%

2.19 (2.55)

PSC positive

12.7%

3.12 (4.72)

Preschool (4-5)

26.3%

2.24 (3.03)

School-Age (6-15)

73.7%

2.49 (2.64)

Not single

72.0%

2.22 (2.79)

Single

28.0%

2.52 (3.27)

Insured

95.6%

2.32 (2.94)

Uninsured

4.4%

2.08 (2.78)

Overall health rating

Parent-reported psych .0001

Age .0001

Marital status .0001

Insurance .0624

B. Bernal et al (2000): ‘Kaiser HMO study’ West Coast HMO pediatric sample • 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’ Patients with externalizing problems had higher costs

F. Guzman et al (2011): ‘Chilean PSC study’ Psychosocial screening for first graders in Chile • Main questions: Can a program for psychosocial screening be implemented in all the low-income schools in a country? • Subjects: 7,903 elementary schoolers

• Methods: PSC given to parents as part 1st grade enrollment and again in 3rd grade; teachers also fill out standardized behavioral screen. Data from a national standardized academic achievement test was collected in 4 th grade. • Results: – Students with psychosocial problems according to parent or teacher reports performed significantly worse on the academic achievement tests in 4th grade – Mental health problems were one of the strongest predictors of lower achievement in 4th grade • Conclusions: Psychosocial problems are prevalent and not adequately managed; the PSC is a good choice as an instrument for screening

F. Mental health and behavior risk in first grade and academic test scores in fourth grade1 Risk in 1st Grade

SIMCE academic achievement test score in 4th grade Summary SIMCE

Math

Science

Language

Behavior Risk

221.82

218.31

226.25

223.17

Behavior OK

242.35***

236.10***

243.70

244.21

Mental Health Risk

225.56

219.31

225.69

230.99

Mentally Healthy

241.56***

237.22***

242.26***

241.40***

Behavior Problem Both

218.32

215.89

224.75

225.09

Behavior Problem on One

230.98

224.40

234.15

234.55

Behavior OK

251.00***

242.39***

249.16***

249.56***

TOCA-RR Risk

PSC-CL Risk

TOCA-RR and PSC Risk

*** p < 0.001 1 Adjusted

for gender, school, SES, mother and father education, father not in home, family member mentally ill, teenage mother, child sick often, family social isolation, and teacher-rated academic problems in first grade.

Rosie D. in Massachusetts Rosie D. v. Romney/Patrick: Class action lawsuit re EPSDT provisions of the Medicaid Act. Under the resulting Children’s Behavioral Health Initiative (CBHI), the state and its providers:  Screen and identify children with serious emotional disturbances (using the PSC, PEDS, M-CHAT, etc.)  Provide comprehensive assessments (CANS)  Provide clinical care management

 Provide home-based services, including crisis services  Notify families of these benefits Website: http://www.mass.gov/eohhs/gov/commissions-andinitiatives/cbhi/screening-for-behavioral-health-conditions/

Rosie D./CBHI Screening Tools

H. Kuhlthau et al (2011): Increased screening in Massachusetts after Rosie D./under CBHI • Screening increased from 16.6% of all Medicaid well-child visits in the 1st quarter of 2008 (start of the program) to 53.6% in the 1st quarter of 2009; the percentage of children with mental health evaluations also increased over a one-year period. • The percentage of screens that identified psychosocial risk decreased slightly, from 11.6% in the 1st quarter of 2008 to 9.2% in the 1st quarter of 2009.

H. Kuhlthau et al (2011): Increased screening in Massachusetts after Rosie D./under CBHI However, due to the large increase in screening, the number of children identified at risk increased substantially from 2,445 in the 1st quarter of 2008 to 5,847 in the 1st quarter of 2009. Number of children identified as at risk

Number of children

6000 5000 4000 Screens identified at risk

3000 2000 1000 0 1 2008 2 2008 3 2008 4 2008 1 2009 Quarter

The impact of mandated screening under Ma. CBHI 1. 75% of all children on Medicaid screened 2.

Of 118,000 records, 9.7% positive (11,400), 70+ % (8000) received mental health services,

43 % (4900) were newly discovered. 3. Does not count families covered by commercial insurance or non-medical mental health providers

= Feasible as a state-wide program

Critical Factors to Facilitate the Work of the Primary Care Pediatrician 1. Reimbursement for screening, affirmation and follow-up. 2. Use of above funding for partial support of co-located mental health clinician as part of a viable financial model of practice. 3. Coordinate CME, Maintenance of Certification, AAP tool kit, “Pediatric Medical Home” training of primary care pediatricians 4. Quality Assurance/IT processes to track those identified as at risk. 5. State services, interagency process, tracking of functioning (CGAS)

Opportunities

• Prevention (Maltreatment) • Early recognition (ADHD/Self esteem, depression, SU)

• Adherence (Diet, medication) • Follow-up (Appointment kept rate, referral) • Stressors (Domestic Violence) • Parental Mental Illness (Depression, psychosis) • Medical and Psychiatric Hospitalization (Care coordination)

• ER Utilization

Potential Models • Reimburse Screening + • State wide CME/Renewal of Certification training

• Co-Location Reimburse Screening to supplement MSW reimbursement, located in office + • Office based groups and education (reimbursement, pay) + • “MCPAP” funded by state +/- Insurance Companies + • Interagency Regional Collaboratives

Likely Future • Global budget payer for costs of care (MH,MRI) • Focus on quality, outcome, practice guidelines, quality assurance, process improvement • Focus on high risk, high cost, outcome, readmissions, palliative care • Focus on coordination

• IT facilitation for broad system of care • Carefully designed incentives, care coordination • Sub-Populations: Medicare, Commercial, Self-insured, Medicaid and Duals; Extensive analytics • Return on Investment (Opportunity for mental health?)

References Bernal P, Estroff DB, Aboudarham JF, Murphy JM, Keller A, Jellinek MS. Psychosocial morbidity: the economic burden in a pediatric health maintenance organization sample. Arch Pediatr Adolesc Med. 2000;154(3): 261-266. Borowsky IW, Mozayeny S, Ireland M. Brief psychosocial screening at health supervision and acute care visits. Pediatrics. 2003;112(1):129133. Centers for Medicare & Medicaid Services. Early and periodic screening, diagnostic, and treatment. 2013; http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-andTreatment.html. Accessed October 4, 2013. Costello EJ, Angold A, Burns BJ, Stangl D, Tweed DL, Erkanli A. (1996). The Great Smoky Mountains Study of youth: Goals, designs, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry. 1996;53(12):1129-1136. Costello EJ, Angold A, March J, Fairbank J. Life events and post-traumatic stress: The development of a new measure for children and adolescents. Psychol Med. 1998;28(6):1275-1288. Gottlieb GL. Strategic Approaches to Embracing Patient Centered Care and Outcomes in the Context of Constricted Resources. PatientCentered Outcomes Seminar. Brigham & Women's Hospital, Boston, MA. 2013. Guzman MP, Jellinek MS, George M, Hartley M, Squicciarini AM, Canenguez KM. (2011). Mental health matters in elementary school; First grade screening predicts fourth grade achievement test scores. Eur Child Adoles Psy. 2011;20(8): 401-11. Hacker K, Penfold R, Arsenault L, Zhang F, Murphy JM, Wissow L. Behavioral health treatment following screening in MassHealth children. Unpublished manuscript, Institute for Community Health. Hacker K, Penfold R, Arsenault L, Zhang F, Murphy JM, Wissow L. New behavioral health issues identified by screening in MassHealth children. Pediatrics. In press. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Third ed. Elk Grove Village, IL: The American Academy of Pediatrics; 2008. Haggerty RJ, Roghmann KJ, Pless IB. The new morbidity. Child Health and the Community. New York, NY: John Wiley & Sons; 1975. Jellinek MS. Population management of ADHD in the era of healthcare redesign. 48th Annual Meeting "Money and Finances: How do we pay for academics in 2013?". Washington, DC: Society of Professors of Child & Adolescent Psychiatry; 2013. Kamin HS, Jellinek MS, Masek BJ, Murphy JM. Using a brief parent-report measure to assess outcomes for children and teens with internalizing disorders. Unpublished manuscript, Massachusetts General Hospital. Kelleher KJ, McInerny TK, Gardner WP, Childs GE, Wasserman RC. (2000). Increasing identification of psychosocial problems: 19791996. Pediatrics. 2000;105(6): 1313-1321.

References (continued) Kuhlthau KA. Jellinek MS, White GW, VanCleave J, Simons J, Murphy JM. Increases in behavioral health screening in pediatric care for Massachusetts Medicaid patients. Arch Pediatr Adolesc Med. 2011;165(7): 660. Langer TS, Michael ST. Life Stress and Mental Health: The Midtown Manhattan Study. London, England: Glencoe: Free Press; 1963. Lowenthal E, Lawler K, Harari N, Moamogwe L, Masunge J, Masedi M, Bolefela M, Seloilwe E, Jellinek MS, Murphy JM, Grossn R. Validation of the Pediatric Symptom Checklist in HIV-infected Batswana. J Child Adolesc Ment Health. 2011;23(1):17-28. Lowenthal E, Lawler K, Harari N, Moamogwe L, Masunge J, Masedi M, Matome B, Seloilwe E, Gross R. Rapid psychosocial function screening test identified treatment failure in HIV+ African youth. AIDS Care. 2012;24(6): 722-727. MassHealth-Approved Standardized Behavioral Health Screening Tools for Children Under the Age of 21. Children's Behavioral Health Initiative 2008; http://www.mass.gov/eohhs/docs/masshealth/cbhi/mh-approved-screening-tools.pdf. Accessed October 16, 2012. McCarthy AE, Guzmán J, Squicciarini A, George M, Canenguez KM, Dunn EC, Baer L, Simonsohn A, Smoller JW, Jellinek MS, Murphy JM. Improving mental health predicts academic progress in elementary school: A large naturalistic study in Chile. MGH Clinical Research Day. Boston, MA. October, 3, 2013. Murphy JM, Ichinose C, Hicks RC, Kingdon D, Crist-Whitzel J, Jordan P, Feldman G, Jellinek MS. Utility of the Pediatric Symptom Checklist as a psychosocial screen to meet the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards: A pilot study. J Pediatr. 1996;129(6): 864-9. Murphy JM, Masek B, Babcock R, Jellinek MS, Gold J, Drubner S, Sklar K, Hacker KA. Measuring outcomes in outpatient child psychiatry: The contribution of electronic technologies and parent report. Clin Child Psychol Psychiatry. 2011;16:146-160. Murphy JM, Pagano ME, Ramirez A, Yolanda Anaya AA, Nowlin C, Jellinek MS.Validation of the Preschool and Early Childhood Functional Assessment Scale (PECFAS). J Child Fam Stud. 199;8(3):343-356. Navon M, Nelson D, Pagano M, Murphy JM. Use of the pediatric symptom checklist in strategies to improve preventive behavioral health care. Psychiatric Services. 2001;52(6):800. United States District Court District of Massachusetts. Rosie D. et al v. Deval Patrick et al. Civil Action No. 01-30199-MAP. Vol F. Supp. 2d 182006. Boston, MA. 2007. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020: Mental health and mental disorders. 2010; http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28. Accessed October 3, 2013. US Department of Health and Human Services, US Department of Education, US Department of Justice. Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington, DC: US Department of Health and Human Services; 2000.