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 Policy Context SAMHSA-funded study methods Description of selected sites Lessons learned Discussion

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) National TANF population 25 % of women had rates of depression in the clinical range; other studies show moderate to severe depression in the 40% range. Head start study found 22% higher rates of children with multiple risks in Head Start

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 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 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 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

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

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: For Adults: 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 Reliability Validity 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 Competencies 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

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 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 Cut down on drinking Annoyance with criticisms about drinking Guilt about drinking Eye opener: using alcohol

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 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 Billing and finances Special populations 96110, 96111 Special populations Sustainability Grant funds Macro-level policy climate

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

How to contact me: Deborah F How to contact me: Deborah F. Perry, PhD Center for Child and Human Development dfp2@georgetown.edu