1. 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

2. Overview Early Childhood Mental Health Policy Context
SAMHSA-funded study methods
Description of selected sites
Lessons learned
Discussion

3. 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

4. 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

5. Social Emotional Development
Inter-relatedness of domains
Intimately tied to caregivers mental health
Core tasks:
Attachment
Behavior
Competence

6. 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

7. 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%)

8. 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)

9. 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

10. Other National Efforts
Starting Early Starting Smart
Early Head Start
Healthy Steps
ABCD
Medical Home Initiative
Bright Futures Mental Health

11. 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

12. Medical Home
A community-based primary care “medical home” is accessible, family-centered. continuous, comprehensive, compassionate, developmentally appropriate coordinated, culturally competent and accountable.

13. 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

14. 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

15. Synthesis of Strategies
Medical Home
Comprehensive Screening
Developmental
Mental Health
Substance Abuse
Behavioral Health Services
Facilitated Referrals
Family as Unit of Care
Cultural Competence

16. 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

17. 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

18. 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%

19. Infant Toddler Social Emotional Assessment
ITSEA… BITSEA: 60 items based upon empirical and clinical concerns
Children ages 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

20. 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

21. 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

22. 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

23. 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?

24. CAGE Questionnaire Cut down on drinking
Annoyance with criticisms about drinking
Guilt about drinking
Eye opener: using alcohol

25. 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

26. 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

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

28. 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

29. How to contact me: Deborah F
How to contact me: Deborah F. Perry, PhD Center for Child and Human Development