Kevin P. Marks, MD FAAP; General Pediatrician at PeaceHealth Medical Group; Clinical Assistant Professor at OHSU School of Medicine, Division of General Pediatrics Identifying & Addressing Developmental-Behavioral Conditions : “Early Interventioners Assemble!”

I do not intend to discuss an unapproved/ investigative use of a commercial product. Financial conflict of interest: I will provide information about a book which was co-authored by myself (but I do not receive any royalties for the ASQ-3 or ASQ:SE-2).

Part I: How can PCPs swiftly identify & address DB problems & better collaborate with early interventionists and other early childhood educators prior to kindergarten entrance?

15-17% of U.S. children (under 16 years of age) have a developmental disability 15-17% of U.S. children (under 16 years of age) have a developmental disability 11-21% of U.S. children have a mental health disorder (as defined by the DSM-V) at any given point in time 11-21% of U.S. children have a mental health disorder (as defined by the DSM-V) at any given point in time 37-39% of U.S children will be diagnosed with a mental health disorder by 16 years of age 37-39% of U.S children will be diagnosed with a mental health disorder by 16 years of age 25-40% of U.S children with a mental health disorder will have at least 1 additional mental health diagnosis at a given point in time % of U.S children with a mental health disorder will have at least 1 additional mental health diagnosis at a given point in time. Developmental and Behavioral Problems Are Very Common Conditions in the USA

1. Early intervention relies heavily upon early identification.

1. Early intervention relies heavily upon early identification. 2. Early identification relies heavily upon those working in the medical, social and educational sectors

1. Early intervention relies heavily upon early identification. 2. Early identification relies heavily upon those working in the medical, social and educational sectors 3. We must wield “mighty” or evidence-based DB screening tools in a planned and periodic manner for children 0 to 5 years of age.

1. Early intervention relies heavily upon early identification. 2. Early identification relies heavily upon those working in the medical, social and educational sectors 3. We must wield “mighty” or evidence-based DB screening tools in a planned and periodic manner for children 0 to 5 years of age. 4. And, after 5 years of age, educators must collaborate closely with PCPs to better address children with DB problems.

Why is Early Intervention So Important? Early Intervention (EI) has been proven to improve long-term developmental outcomes (most especially in children who are “disadvantaged” or have mild delays or early signs of autism)

Why Else is Early Intervention So Important? Improved outcomes at 18 years = higher achievement in math & reading + less antisocial/criminal behaviors, less suicidal thoughts/attempts, less smoking, alcohol & marijuana use (McCormick et al, Pediatrics, 2006)

With behavioral/mental health disorders, there’s an approximately 2- to 4-year window of opportunity between symptom appearance and when the child meets DSM-V criteria for a disorder. With behavioral/mental health disorders, there’s an approximately 2- to 4-year window of opportunity between symptom appearance and when the child meets DSM-V criteria for a disorder. Evidence strongly suggests there are opportunities for secondary prevention or early intervention. Evidence strongly suggests there are opportunities for secondary prevention or early intervention. Source: U.S. National Research Council and U.S. Institute of Medicine Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young Adults Why Else is Early Intervention So Important?

Early intervention relies upon early identification: What is the best setting(s) for early identification with periodic developmental-behavioral (DB) screening? a. Nurse home visits (social sector) b. Primary care providers (medical sector) c. Early childhood educators (education sector) d. All of the above

Early identification relies heavily upon those working in the medical, social and educational sectors And, we must collaborate together because for every $1 invested in an early childhood developmental program, there is a 6-10% annual return rate in there is a 6-10% annual return rate in cost savings to society! ~Dr. James Heckman, a Nobel Laureate in Economics & many other well-respected economists

Pediatrician impression alone (DB surveillance without periodic screening) fails to timely identify & refer 60 – 80% of children with developmental-behavioral delays Only 30% of developmental disabilities identified without screening tools (Palfrey et al. JPEDS. 1994) Only 30% of developmental disabilities identified without screening tools (Palfrey et al. JPEDS. 1994) 70-80% with developmental disabilities correctly identified with screening tools (Squires et al., JDBP 1996) 70-80% with developmental disabilities correctly identified with screening tools (Squires et al., JDBP 1996) Only 20% of mental health problems identified without screening tools (Lavigne et al. Pediatrics. 1993) Only 20% of mental health problems identified without screening tools (Lavigne et al. Pediatrics. 1993) 80-90% with mental health problems correctly identified with high- quality screening tools (Sturner, JDBP 1991) 80-90% with mental health problems correctly identified with high- quality screening tools (Sturner, JDBP 1991) We must wield “mighty” or evidence-based DB screening tools in a planned & periodic manner for children 0-5 years.

Many PCPs Use Screening Tools to Measure DB Risk Factors 2 wks: Survey of Well-being of Young Children (SWYC) “Family Questions” Screens parents for: a) tobacco & drug abuse, b) food insecurity, c) depression, d) intimate partner violence Screens parents for: a) tobacco & drug abuse, b) food insecurity, c) depression, d) intimate partner violence 2, 4 or 6 mo: Edinburgh Post Natal Depression Scale (EPDS) Screens for maternal depression/anxiety Screens for maternal depression/anxiety Score = 12? Question #10 concerning? Score = 12? Question #10 concerning? 4 mo: ACE Questionnaire: (score >3 means action needed??) Screens for parental adverse childhood experiences Screens for parental adverse childhood experiences Not commonly being used in our community. Not commonly being used in our community.

AAP General Developmental Screening Periodicity Schedule (0 to 5 years) PCPs administer a pre-visit, broad-band developmental screen (e.g., ASQ-3) routinely at 9, 18, 24 or 30 months + 4 years to measure “kindergarten readiness” + as needed when “at risk” for a developmental delay Dr. Marks: 6, 9, 12, 18, 24 & 36 mo. + as needed

Beyond identifying DDs, we must swiftly identify & refer children with emerging social-emotional problems to EI/ECSE, mental health providers & “high-quality” preschools!

AAP Social-Emotional Screening Periodicity Schedule (0 to 5 years) PCP administers a pre-visit, social-emotional screen (e.g., ASQ:SE-2) routinely at 5 years + as needed Dr. Marks: 18 months & 4 years + as needed.

Medical assistant (MA) makes sure that caregiver(s) complete the DB screening tool before the PCP walks into the exam room.

Super Hero PCPs Take Action on (+) Screens Discusses the child’s “areas of strength” first. Discusses the child’s “areas of strength” first. Discusses the child’s “suspected challenges” second. Discusses the child’s “suspected challenges” second. Initially resists using diagnostic labels. Initially resists using diagnostic labels. Does NOT take a “wait and see” approach with a concerning ASQ result or clinical impression. Does NOT take a “wait and see” approach with a concerning ASQ result or clinical impression. DOES say “let’s play it safe and give them a call” (i.e., links child to EI/ECSE when indicated). DOES say “let’s play it safe and give them a call” (i.e., links child to EI/ECSE when indicated). DOES reliably communicate their recommendations with parents in a culturally appropriate manner. DOES reliably communicate their recommendations with parents in a culturally appropriate manner.

DB Screening Must Be Paired with Care Coordination! For children needing a referral, PCP sends a care coordinator an electronic or “lightning bolt” encounter about their interpretation of the ASQ-3 or ASQ:SE-2 results & a care coordinator links children/families to the most effective community resource.

Part II: After kindergarten entry, how can educators collaborate closely with PCPs to better identify & address children with DB problems?

The First Interventioner Recognizes a potentially impairing DB concern & contacts the child’s caregiver(s) to get their get signed consent (HIPPA & FERPA) to exchange information between the school & medical home or PCP.

Then, (written or verbal) information is exchanged in a timely manner between the medical home and school.

PCPs should do evaluations and/or refer to mental health. Then, the PCP should complete medical or health assessment statements in a timely manner.

Condition #1: ADHD (Tony Stark/Iron Man)