Implementing Mental Health

Screening Tools

Andres Pumariega, MD

Michael Roberts, PsyD

– Andres Pumariega, MD, receives grant support from the NJ Dept. of Child and Family Services and support from AmeriHealth of NJ (consultant) and RiverMend Health (Scientific Advisory Board). Dr. Pumariega does not plan on discussing commercial products or services.

– Michael Roberts - No Disclosures to Report Related to This Training

Disclosures

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Outline

– An in-depth look at the SWYC and PSC-35, including scoring and case studies

– Incorporating mental health screening in your busy practice

– Talking to Families about Mental Health Screening

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Why the Early Childhood Medical Home?

– Unique and comprehensive, unstigmatized access to early childhood

– Public’s deep respect for pediatricians as trusted guardians of child health

– Number of well-child visits from birth to age 5

– 97% of infants and toddlers have regular access to healthcare (CDC, 2006)

– Federal mandate for EPSDT for Medicaid covered children.

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Parents’ Top Reasons for Attending Well-Care Visits

• Promoting Health Immunizations Screening Referrals

• Requirements School, child care, sports

• Reassurance Is my child okay? Am I doing okay as a parent?

• Opportunities for Discussion Parent priorities are key

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It’s What Parents Want!– McCune et al reported that 81% of parental

questions for pediatricians concerned psychosocial issues

– In their study, parenting issues were parents' predominant concern: 70% of mothers were more worried about some aspect of their parenting or their child's behavior than they were about their child's physical health

– Access to behavioral health services is very limited and going to a mental health provider can be seen as stigmatizing

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Every Day, Every Child: 5 Rs of Early Childhood

• Routines help children know what to expect of us and what is expected of them

• Reading together daily

• Rhyming, playing and cuddling

• Rewards for everyday successes – PRAISE is a powerful reward

• Relationships, reciprocal and nurturing –foundation of healthy children

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Barriers Time, time, time

“One more thing”

Reimbursement

Education and knowledge

Perceived or real lack of community resources

“I identified an issue, now what??”

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Green, Yellow, Red

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Surveillance

Screening

•SWYC

•PSC-35, Y-PSC

GREEN:Universal Surveillance & Screening

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Practice staff attempts to get child some help for lower order issues, including:

• Based on the screening, decide if secondary screening is necessary

• Community resource referral to family support organizations, parenting group, etc.

• Early Intervention or Help Me Grow• Head Start/other educational resource for

child• Consider contacting the Peds Collab Hub

for consult

YELLOW: Pediatricians’ Care Coordination

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Call the Cooper Hub: (856) 757-7719

If appropriate call DCP&P if there is a concern about child safety issues

RED: HUB Consultation

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Screening

Surveillance vs. ScreeningSurveillance

• Informal way to see what is going on with a family.

• “How are things going at home, school, with friends?”

Screening

• Using a validated, standardized screening tool at designated intervals to help identify children with developmental delay, social, emotional and/or behavioral issues.

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Surveillance and Screening

• One does not replace the other

• Begin by attending to parent concerns– “Do you have any specific concerns about your

child’s development, emotional functioning, learning or behavior?”

• Screening at regular intervals improves earlydetection of behavioral and mental health issues.

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The Importance of Standardized Screening

• Not all cases will be identified via routine interview, or “eye-balling” patient/ family . . .– Most clinicians eyeball the child and ask a couple of

questions.

– May be fine for physical delays, but is not a good way to identify children with mild cognitive/developmental disabilities, communication problems, emotional and behavioral problems, or delays in social development.

– 70-80% of children with developmental problems will be missed if a standardized approach is not applied. Alternatively, if a structured, standardized instrument is used, 70-80% will be identified.

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The Importance of Standardized Screening (cont.)

– Parents Often Underestimate Symptoms:

Literature suggests parents best report externalizing problems while children best report internalizing problems

Children may withhold complaints because of concerns they are abnormal, or to protect parents who are upset

Parents may not think professionals are interested or assume “normal reactions to abnormal event”

Stigma related to mental illness17

Does Screening Mean Becoming an Expert in Development or Mental

Health?

Screening uses population norms to identify those at risk. Identified children are referred for assessment. Assessment determines the existence of a developmental delay or mental health issue which generates a decision regarding intervention.

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AAP Mental Health Toolkit

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How might surveillance and screening look?

Pediatric Well Visit Initial MH Screening

◦ Front desk hands out the screening (paper or electronic)

◦ Nurse scores it before doctor sees patient (or EMR scores and drops into patient’s record)

Based on results, discussion with parent and possible call to case manager Possible secondary screening Results may indicate referral to Hub to determine referrals May require psychiatrist consult

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Social Emotional Screening for Babies, Toddlers, and Preschoolers

SWYC - Survey on the Wellbeing of Young Children:

– Comprehensive surveillance or first-level screening instrument for routine use in regular well child care

– Covers developmental milestones and social/emotional development

– Combines what is traditionally “developmental” with traditionally “behavioral” screening

– Freely-available, takes 10-15 minutes to complete, for ages 2 months – 5 years

Tufts University School of Medicine, http://www.theswyc.org/21

– Baby Pediatric Symptom Checklist (BPSC) – a social/emotional screening instrument for children under 18 months of age.

– Preschool Pediatric Symptom Checklist (PPSC) –a social/emotional screening instrument for children 18-60 months of age.

– Developmental Milestones questions include indicators of fine and gross motor, language, social, and cognitive development.

Parts of the SWYC

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Available at: http://www.theswyc.org/

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Scoring for Milestones Score each item

• Not yet= 0

• Somewhat = 1

• Very much = 2

Add items 1-10

Match age in far left column

“Below average” requires further evaluation

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A Closer Look – SWYC (Preschool Pediatric Symptom Checklist)

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• “Robert W. Johnson” –

• 3 year old presents for a well child visit with aggressive behavior, as reported by teacher to parents, and as experienced by parents at home.

Case Study 1 – Using the SWYC (PPSC)

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Case Study 1 – Using the SWYC (PPSC)

Score: 16

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Scoring Instructions:1. Determine the PPSC total score by assigning a “0” for

each “not at all” response, a “1” for each “somewhat” response, and a “2” for each “very much” response, and sum the results.

2. For items where parents have selected multiple responses for a single question, choose the more concerning answer (i.e. "somewhat" or "very much") farthest to the right.3. A missing item counts as zero.

Interpretation: o A PPSC total score of 9 or greater indicates that a child is "at

risk" and needs further evaluation.

Scoring of the SWYC (PPSC)

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Pediatric Symptom Checklist (PSC-35, Y-PSC)

If needed, secondary screening may be considered:

Personal Health Questionnaire-9 (PHQ-9) or

PHQ-A (Adolescents) for Depression

SCARED or GAD-7 (both for Anxiety)

Mood Disorder Questionnaire (MDQ) Bipolar

SNAP-IV- 18 for ADHD

Others (Y-BOCS-C for OCD, EAT-26 for eating disorders, etc.)

Social Emotional Screening for Older Children & Adolescents

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Pediatric Symptom Checklist (PSC-35, Y-PSC)

– A psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible.

– Designed by Michael Jellinek, M.D., Pediatrician and Child Psychiatrist, Mass General, and colleagues

– Assessment can be used for ages 6 to 18

– Available in multiple languages and a pictorial version

– Parent version available for young children ages 6 to 11 and self assessment from age 11 and up (Y - PSC).

• Parent measure can also be used for ages 4-5http://www.massgeneral.org/psychiatry/services/psc

_scoring.aspx 30

Pediatric Symptom Checklist (PSC-35)

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Pediatric Symptom Checklist (Y-PSC)

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The PSC consists of a total score, as well as three subscales.

To calculate the total score, use the following key:• Never = 0• Sometimes = 1• Often = 2

For the total score, the cut-offs are as follows:• Ages 6-18: score >/= 28 is significant• Ages 4-5: score >/= 24 is significant

For children ages 4-5, the scores on elementary school related items 5, 6, 17 and 18 are ignored

• Y-PSC: score >/= 30 is significant

PSC Scoring

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Attention Subscale:– Sum responses to items 4, 7, 8, 9, 14

• 7 or higher is considered significant

Internalization Subscale (Mood/Anxiety Symptoms):– Sum responses to items 11, 13, 19, 22, and 27

• 5 or higher is considered significant

Externalization (ODD / Conduct Disorder):– Sum responses to items 16, 29, 31, 32, 33, 34, and 35

• 7 of higher is considered significant

PSC Subscale Scoring

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Case 2: Using the PSC-35

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Female patient, age 9

Presented to Dr. w/high anxiety and sleep issues

Academic difficulties with IEP in school

Generalized anxiety, also fear of separation from the mother

She scored a 35 on the PSC-35

• 9/17/15: After initial phone call with physician, the pediatrician’s office was sent secondary screeners for the family to complete. The pediatrician then forwarded the screeners to the family, who completed the forms and submitted them back to the primary care office.

• 9/17/15: The family was sent a list of referrals for therapy services, specifically behavioral therapy, and the referrals were discussed over the phone.

• 9/28/15: The Hub received the secondary screeners form the pediatrician’s office. The screening tools were scored and results were reviewed with the mother and pediatrician. Hub staff psychologist had an extended telephone conversation with patient's mother. Provided her with education regarding best possible treatment plans for anxiety and inattention symptoms. Psychologist also provided her with some sleep hygiene tips that she can try at home to prepare the patient to be able to commit to sleep at a regular time.

• 9/30/15: Due to the patient’s relatively high score on an attention measure. The

consulting pediatrician was contacted by Hub staff psychiatrist to discuss medications.

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Case 2: Hub follow-up

Tips for Communicating Results

Attend to parent concerns

Clear communication

Communicate concerns within the context of specific strengths

Delineate clear action steps

Provide ongoing support

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What Do I Do Once I’ve Identified A Risk?

– Assess the child/families strengths by looking at their:

• Connection/Belonging

• Competence/ Mastery

• Independent decision-making

• Helping out (family and/or community)

– What are the families’:• Assets

• Resources

• Resiliencies38

• SERIES: An Integrated Approach to Supporting Child Development – both physically and emotionally

• Screening

• Early Identification

• Referral

• Intake

• Evaluation

• Services

What Do I Do Once I’ve Identified A Risk? (continued)

Policy Lab, CENTER TO BRIDGE RESEARCH, PRACTICE & POLICY, Children’s Hospital of

Philadelphia Evidence to Action, Summer 2012

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QUESTIONS?40

Making This Work in Your Practice

Meridian Cooper Collaborative Program

Cooper Hub phone line: (856) 757-7719

Regional Intake Line 1-800-649-2778

Case Manager helps arrange evaluation

Assessment and Evaluation occur at no cost for family (sliding scale for services)

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Additional Resources• CDC

– http://www.cdc.gov/

• Birth to 5: Watch me thrive– http://www.acf.hhs.gov/programs/ecd/child-

health-development/watch-me-thrive

• American Academy of Pediatrics– http://www2.aap.org/sections/dbpeds/screening.a

sp

• Center for Medical Home Implementation– http://www.medicalhomeinfo.org/

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Strategies for Implementation

Considerations for Implementation

Set a goal

Choose a screening tool

Assess your work flow including EMR if applicable

Identify roles for team members

Set up a plan for tracking

Get to know community providers

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Take Away Messages

Educate and partner with families to help link them to services

Simplify the referral process for families when you can

Be aware of families with low health literacy

Create a work flow for your practice

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Ways to Evaluate & Support Relationships

Ensure the mental health of parent and child are addressed at each visit (may include parental and family history)

Use open-ended questions as well as screens Adapt Bright Futures Guidelines Use screening protocols Have other staff to engage in education Connect families with resources (child care, parenting

groups, etc.) Link into Patient Centered Medical Home (PCMH)

and Quality Improvement (QI) efforts49

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Resources

• American Academy of Pediatrics’• National Center for Medical Home

Implementation (NCMHI) http://www.medicalhomeinfo.org/

• NCQA Patient Centered Medical Home:• http://www.ncqa.org/Programs/Recognition/P

ractices/PatientCenteredMedicalHomePCMH.aspx

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Communicating and Connecting

Everyone Brings Their Culture

Cultural Identity

Systems of Patient

Cultural Identity

Systems of Provider

ClinicalEncounter

Issues inCommunication• Stereotyping• Rapport• Satisfaction• Compliance• Responsibility

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Factors Impacting Effective Communication

– Cultural beliefs/ attitudes

– Trust/Mistrust

– Low Health Literacy

– Language Access

– Spiritual and Religious beliefs

– Sexual Orientation/Gender Identity/Gender Expression

– Disabilities and Other Special Needs

– Bias and Stereotyping (esp. when clinicians project our own biases; see Institute of Medicine, 2002)

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BATHE: A Useful Mnemonic for Eliciting the Psychosocial Context

B Background

A Affect

T Trouble

H Handling

E Empathy

From: Stuart MR, Lieberman, JA III, Rakel, RE (FRW). The Fifteen Minute Hour: Therapeutic

Talk in Primary Care, 4th Edition. Oxford and New York: Radcliffe Publishing, 2008.

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The Basics of Creating a Safe Environment

Ask Open-Ended Questions

– Can’t be answered yes/no

– Use patient’s own words

– Ask questions in a tone that invites openness

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The Basics of Creating a Safe Environment (cont’d)

Pay Attention to Non-Verbal Communication

– Put patient at ease

– Your body language

– Facial expressions

– Use eye contact

– Convey respect

– Interview in a private setting

– Pay attention to patient’s body language56

The Basics of Creating a Safe Environment (cont’d)

Convey Care and Empathy

– Acknowledge their feelings

– Use language that is non-judgmental

– Consider things through the family’s lens

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Common Factors Interventions - H.E.L.P.

HOPE

EMPATHY

LANGUAGE and LOYALTY

PERMISSION, PARTNERSHIP and PLAN

AAP Mental Health Toolkit58

“Feelings Need Check-Ups Too”

– AAP resource and toolkit on crisis-related mental health problems

– Case study approach

– Demo of various screening tools

– Info on parental reassurance and bereavement support

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Feelings-Need-Checkups-Too-Toolkit.aspx#sthash.BL9i0Ovc.dpuf 59

The key to thriving relationships is open, honest communication

Active listening is a core skill for pediatric practice but many external forces can get in the way

This is an opportunity to revisit and to identify how we can apply some of these principles in our practice

Introduction to Active Listening

Adapted from Gordon, 2000 60

Communication Road Blocks Ordering, directing,

Warning, threatening,

Preaching, moralizing,

Giving solutions, suggestions

Lecturing, teaching

Criticizing, disagreeing

Praising, agreeing

Name calling, shaming

Interpreting

Reassuring

Interrogating, probing

Withdrawing, distracting

Adapted from Gordon, 2000 61

– Invitations to say more

o “Door Openers”o Examples- “I see”, “Tell me more”, “Tell me about it”

Active listening o “Keeping the door open”

o Decoding messages

Tools to keep communication going

Adapted from Gordon, 2000 62

Care Coordination

Care Coordination

– Assess current protocols

– Assign new roles in office

– Identify system supports

– Develop system for follow-up

– Schedule re-visit(s) as needed to check-in

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After screening the patient using the SWYC, PSC-35 and/or Y-PSC, pediatrician can contact the Hub via telephone.

You will be asked to discuss relevant background information, current clinical picture, demographic information, and reason for referral.

Depending on referral question you will either receive:• Consultation with a CAP regarding medication

recommendations• Secondary screening assessment tools provided by the Hub

for the family to complete• Diagnostic opinion / care coordination / referral resources by

Hub Staff

Collaborative Hub Procedure

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CARE COORDINATION:

• If you have discussed the Hub with patient and family, staff psychologist / LCSW can contact the family and discuss current concerns and suggestions for treatment.

• The family is then sent a list of referrals for therapy services to address current mental health concerns.

• These referrals are researched by staff psychologists / LCSWs, and most often accept patient insurances.

Collaborative Hub Procedure

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– To aid the pediatrician with patient care via medication consultation and care coordination.

• The Hub will only perform face to face patient consults in emergency or complex situations.

– To encourage and improve screening for behavioral and mental health issues in primary care.

Purpose of the Hub

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The Win/Win Healthy, thriving children as a result of building

lifelong health and an economically sound and thriving community/society

Opens up professional doors and opportunities for you and the families and communities you serve

It’s fun and rewarding!!!!

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Linkagesto Community Resources

Children’s System of Care (CSOC)

Committed to providing services based on the needs of the child and family in a family-centered, community-based environment.

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Children’s System of Care (CSOC) (continued )

• Serves children and adolescents:

– in need of behavioral and mental health services

– in need of substance abuse services up to age 21

– with intellectual and developmental disabilities up to age 21

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PerformCare

– Single point of entry for all children, youth and young adults entering the New Jersey Children’s System of Care.

– Goal is to help families and caregivers create a more stable and healing environment for children, address barriers to well-being, and maximize youth and family strengths.

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PerformCare– Families should call if their child’s behavior has

changed from normal or if they are overwhelmed by challenges at home or in the community.

ChildBehavior

1-877-652-7624

TTY: 1-866-896-6975

Available 24 hours a day, 7 days a week

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Resources - State

• Mental Health Cares Hotline – 1-866-202-4357• PerformCare – 1-877-652-7624

Mental Health

• 211 (Available 24/7)• NJ Help –www.njhelps.org • NJ Housing Resource Center – 1-877-428-8844• End Hunger NJ – www.endhungernj.org

Help with Basic

Needs

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QUESTIONS?75

Brief Motivational Interviewing: Enhancing Behavior Change and Treatment Participation

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Identify challenges in health behavior change conversations and communication roadblocks

Learn about the principles and techniques of MI

(spirit & method)

Learn about the use of Open Questions and Reflective Listening

Explore how MI can increase motivation for treatment adherence in primary care

Objectives and Agenda

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What is Motivational Interviewing?

Collaborative, accepting conversational style

Elicits and strengthens patient’s own motivations

Helps patient talk more about positive change

For

change

Against

change

Ambivalence78

Stages of Change

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Listening for the Language of Change

• Uphill: D esire – “I want to” / “I would like to”

A bility – “I could” / “I can” / “I might be able to”

R easons – “I need to feel better for the sake of …”

N eed – “I ought to” / “I have to”

• Downhill: C ommitment – “I am going to” / “I will”

A ctivation - “I am planning to …”

T aking steps – “I actually went out and …”

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What are the core MI skills? O pen questions vs. closed questions

A ffirmations (acknowledging strengths)

R eflections (simple/complex)

S ummaries (transitional/linking)

Partnership Acceptance

EvocationCompassion

MI Spirit

Involvement

Cooperation

Change Talk

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What are the core MI skills? O pen questions vs. closed questions

“What” and “How”, instead of closed-ended / yes and no questions

A ffirmations

Acknowledging a patient’s strengths, what are they good at, what have they already done to change or improve behavior

R eflections (Simple vs Complex)

Statements communicating empathy / guessing at the meaning of what patient is saying

S ummaries (Transitional/Linking)

Reflection of key points of patient’s story

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Brief Consults and the 3-Step CHANGE model

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CHANGE model

STEP 1: BUILD RAPPORT/ELICIT STORY

C heck patient’s perspective about health related behavioral problems (Open-ended Questions)

H ear what the patient says (Reflective Listening, Summaries)

A void MI-inconsistent behaviors (Unsolicited advice / Direct confrontation)

Reflect more than you ask - Listening saves time!

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CHANGE modelSTEP 2: ASSESS & DEVELOP MOTIVATION

N ote patient’s behavior change priorities and commitments using:

◦ Importance level◦ Confidence and ⁄ or readiness ruler strategies◦ Determine the patient’s change commitments

Evoke change talk with open questions:

“What would have to happen to make this change more important for you?”

“Of all the areas we discussed, which ones do you feel are most important?”

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Importance and Confidence Rulers

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CHANGE model

STEP 3: END WITH SUMMARY AND PLAN (IF READY)

G ive advice / feedback only when solicited or with patient’s

permission

E nd the interview with a summary of patient’s plans for change and

medical follow-up

4 PROCESSES IN A CHANGE CONVERSATION: Engaging, Focusing, Evoking, Planning

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Motivational Interviewing and Primary Care

How might motivational interviewing be effective in primary care?

• Improving follow-through for behavioral health recommendations

• Improving treatment adherence

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MI Resources

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QUESTIONS?90

• Special thanks to:

Manuel Jimenez, MD, MS

Raymond Hanbury, PHD

NJ AAP Pediatric Partnership Initiative Content Experts:

• Colleen Kraft, MD, FAAP• Steven Kairys, MD, MPH, FAAP• Robert Like, MD, MS

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Acknowledgements