After the screen… Katherine Hobbs Knutson MD MPH Elizabeth Rihani, Manager, Child Find-Early Stages DC Learning Collaborative February 6, 2015

Disclosures No relevant disclosures. No relevant conflicts of interest. There will be no discussion of off-label use of medications.

Learning Objectives Identify screening tools and potential results. Based on screening results, develop methods for further evaluation. Identify when specialty referral may be indicated and community resources for referral. Introduce treatment methods for behavioral health problems within primary care.

Screening tools Edinburgh postnatal depression scale (EPDS) Ages & Stages questionnaire – social emotional (ASQ-SE) Strengths & Difficulties questionnaire (SDQ) Add CRAFFT & suicide screen for teens Patient Health Questionnaire-9 (PHQ-9)

Setting the stage for screening Before providing the screen, prepare parents and youth in advance. Pamphlets or videos in the waiting area and exam rooms to expose parents to the concept of behavioral-health screening Clarify what screening means: not a diagnosis It is natural for families to feel apprehensive around MH discussions Apprehension eases when the screening process is explained How medical staff approaches topic of MH with a family can impact family’s understanding of and participation in interventions Use the idea of a partnership, conveying respect for the parents as an expert on the child and continually seeking their perspective on the child and the situation

Discussion of a negative screen If the results of the screen are reassuring (“negative”) Acknowledge as such to the parent/guardian and youth “Things seem to be going well-- that’s terrific.” Ask if any questions came up while the form was being completed This can help to build the provider-patient relationship More likely to come to you if mental health issues emerge in the future Don’t forget to document and bill for screening CPT code 96110 (TS modifier for at risk screens)

Negative screen Provide anticipatory guidance for social and emotional development for the upcoming year. Explain that screening will continue annually. Encourage families to contact providers with social, emotional or behavioral concerns.

Borderline screen Consider reevaluating in 1 month

Borderline or positive results Next we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Discuss concerning sections with the family (at the current or a subsequent visit) Clarify that the screen does not make a diagnosis Next we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Discuss concerning sections with the family (at the current or a subsequent visit) Clarify that the screen does not make a diagnosis Goal: Make decisions about management Follow and reevaluate Manage within primary care Refer for specialty care Next we will walk through questions to ask during the discussion with families to support triage decisions.

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Gather information about the following: Nature of the problem Impact of the problem on function Safety issues

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Gather information about the following: Nature of the problem Developmental concerns Behavioral concerns Impact of the problem on function Home: limit setting, dangerous/safety concerns, eloping School: grades, attendance Peers: quality of friendships, social engagement Safety issues Substance abuse Suicide Psychosis

Borderline or positive results Nature of the problem: Use the screening results to guide the discussion. Identify comorbid conditions. Consider adding questions. 0-3yo strong start/EI 3-5yo Early Stages (DCPS)/Child Find

Borderline or positive results Nature of the problem: Developmental concerns (including autism): Motor Verbal Cognitive/adaptive Use the screening results to guide the discussion. Identify comorbid conditions. Consider adding questions. 0-3yo strong start/EI 3-5yo Early Stages (DCPS)/Child Find

Borderline or positive results Nature of the problem: Developmental concerns (including autism): Motor Verbal Cognitive/adaptive Behavioral concerns: with an ear toward… ADHD Anxiety Depression Substance abuse Oppositional behavior Use the screening results to guide the discussion. Identify comorbid conditions. Consider adding questions. 0-3yo strong start/EI 3-5yo Early Stages (DCPS)/Child Find

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Impact of the problem on function Consider the impact supplement for the SDQ

SDQ Impact Supplement SDQinfo.org ~ Severity ~ History 1 2 ~ Impairment 1 = Borderline 2+ = Clinical

Borderline or positive results Impact of the problem on function Home School Peers/community

Borderline or positive results Impact of the problem on function Home School Peers/community

Borderline or positive results Impact of the problem on function Home: Do caregivers feel capable of limit setting and managing behavior (special case: foster care)? Does the family feel safe? Does the child/teen elope? Is there significant distress at home due to the child’s behavior? Does the child’s behavior impact family functioning (e.g., ability to go to the store, remain employed)

Borderline or positive results Impact of the problem on function Home School Peers/community

Borderline or positive results Impact of the problem on function School: Attendance. Grades declining. Suspensions/disciplinary measures.

Borderline or positive results Impact of the problem on function Home School Peers/community

Borderline or positive results Impact of the problem on function Peers/community: Quality of friendships. Social engagement/withdrawal (teens: texting, social media). Legal issues.

Borderline or positive results Impact of the problem on function Home School Peers/community

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Safety issues Substance abuse Suicide Psychosis

Borderline or positive results Safety issues Substance abuse “Do you or your friends use drugs or alcohol?” If yes, then clarify types of drugs, amount & frequency of use.

Borderline or positive results Safety issues Suicide “Do you ever have thoughts about hurting yourself or sometimes wish you weren’t alive?” If yes, then clarify Any recent suicide attempt. Any plan or intent for suicide attempt currently or in the recent past.

Borderline or positive results Safety issues Psychosis “Do you ever hear voices that others don’t hear?” If yes, then clarify if the voice(s) instruct the patient to do things – with particular attention to instructions to do anything dangerous. Also helpful to clarify if the voice is the child’s own voice or another.

Borderline or positive results Safety issues Substance abuse Suicide Psychosis

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Borderline or positive results Gather information about the following: Nature of the problem Developmental concerns Behavioral concerns Impact of the problem on function Home: limit setting, dangerous/safety concerns, eloping, family distress School: grades, attendance Peers: quality of friendships, social engagement Safety issues Substance abuse Suicide Psychosis Summarize

Triage decision following a borderline or positive screen

Triage decision following a borderline or positive screen Developmental concerns (including autism): Motor Verbal Cognitive/adaptive

District of Columbia Public Schools - Early Stages Making Referrals For children who are DC residents or who attend a DC child development center or private school Strong Start Early Stages Age Range: Birth to 2 years 10 ½ months 2 years 8 months to 5 years 10 months Reason: Developmental delay Diagnosed condition or risk factor associated with developmental delay Parental concern Same as Strong Start Concerns over school readiness and social- emotional issues Examples: Very low birth weight, genetic condition, prematurity, hearing or vision impairments, birth defects, delayed speech, autism spectrum disorders Most common: speech delay, developmental delay, as well as physical and fine motor concerns. I think it may be worth touching on the complexity of behavior referrals

Areas of Evaluation A little bit of everything Fine Motor Development District of Columbia Public Schools - Early Stages Education A little bit of everything Speech and Language Fluency Articulation Comprehension Occupational Therapy Fine Motor Development Sensory Processing Physical Therapy Gross Motor Development Psychological Autism Concerns Behavior Adaptive and Social Skills Cognitive Strong Start T: (202) 727-3665 I www.strongstartdc.com I Early Stages I T 202.698.8037 I www.earlystagesdc.org

2 years, 8 months - 5 years, 10 months District of Columbia Public Schools - Early Stages Where to Refer Birth – 2 years, 8 months 2 years, 8 months - 5 years, 10 months Phone 202-727-3665 Email osse.dceip@dc.gov Web www.strongstartdc.com Phone 202-698-8037 Email referrals@earlystagesdc.org Web www.earlystagesdc.org

Answer the following questions: District of Columbia Public Schools - Early Stages Determining Eligibility Answer the following questions: Does the student have an IDEA-defined disability? AND Does the disability have an impact on the child’s education? If YES (to both): Student is eligible for special education and related services; an IEP must be developed. If NO: Determine if the student is eligible for accommodations under Section 504 and/or refer for school-based support.

Disabilities Under IDEA District of Columbia Public Schools - Early Stages Disabilities Under IDEA Autism Deaf-Blindness Deafness Developmental Delay Emotional Disturbance Hearing Impairment Intellectual Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment (inc. Blindness)

IEP Services Specialized Instruction Speech/Language Therapy District of Columbia Public Schools - Early Stages IEP Services Special education is specially designed instruction that ensures the child’s access to the general curriculum. Related services, if determined necessary, may include: Specialized Instruction Speech/Language Therapy Physical Therapy Occupational Therapy Psychological Services Audiology Services Interpreting Services Transportation Vision Services Extended School Year (ESY) Assistive Technology Devices Medical Services School Health Services and School Nurse Services

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Triage decision Behavior concerns without impact on function or safety concerns Consider providing guidance for caregivers & reassess in 1 month

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Triage decision Behavior concerns with impact on function

Triage decision Behavior concerns with impact on function Consider treating within primary care (ADHD, anxiety, depression, substance abuse)

Treatment within primary care ADHD Choose your favorite screening tool (Vanderbilt, SNAP, etc.). If the child has ADHD symptoms at school and at home that started prior to age 7yo with significant impact on function, then consider treatment (meds, therapy). Consider referral for IEP/504 at school. Follow up within 1 month of initiating treatment.

Treatment within primary care Anxiety Consider another screening tool such as SCARED. Treatment: Therapy. SSRI medication for severe impact of anxiety on function and/or continued anxiety symptoms despite at least 6 weeks of therapy. Consider referral for IEP/504 at school.

Treatment within primary care Depression Consider another screening tool such as PHQ-9. Treatment: Therapy. SSRI medication for severe impact of depression on function and/or continued anxiety symptoms despite at least 6 weeks of therapy. Consider referral for IEP/504 at school.

Treatment within primary care Initiation of SSRI medication Rule out history of mania. Decreased need for sleep + severe behavioral dysregulation, rapid speech, grandiose thoughts, reckless behavior. Warn families about risk of suicidal ideation. Rare, incremental risk, call 911 for any concerns. Warn families about initial side effects including GI upset and headache that will resolve. Follow up within 1-2 weeks of initiating SSRI medication.

Treatment within primary care Substance abuse Gain an understanding of all drugs being used and quantities. Motivational interviewing: Cutting down on drug use. Engaging in substance abuse treatment.

Triage decision Behavior concerns with impact on function Consider treating within primary care (ADHD, anxiety, depression, substance abuse) Consider referring for mental health evaluation Resource guide DC MAP care coordinator

DC Mental Health Resource Guide: DCHEALTHCHECK.NET

Triage decision Behavior concerns with impact on function Consider treating within primary care (ADHD, anxiety, depression, substance abuse) Consider referring for mental health evaluation Resource guide DC MAP care coordinator Behavior problems impacting academic progress and/or development: refer for Strong Start, Early Stages, or IEP/504 depending on age

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Triage decision Behavior issues with safety concerns Consider calling CHAMPS (202.481.1450) or sending to ED Active suicidal thoughts, recent suicide attempt, psychosis, severe substance abuse Urgent referral for mental health if available Self-injurious behavior, passive suicidal thoughts, less severe drug use Consider scheduling another visit in 2-3 days while waiting for mental health evaluation CHAMPS number

Triage decision following a borderline or positive screen Borderline/Positive screen Developmental concerns Refer for Strong Start, Early Stages, or IEP/504 depending on age Behavior concerns No functional impairment or safety concerns Provide guidance & follow in one month With functional impairment Treat in primary care Refer to specialty care With safety concerns Refer to ED Refer for urgent mental health evaluation Triage decision following a borderline or positive screen This is the triage decision tree – we will walk through questions to ask during the discussion with families to support triage decisions.

Learning Objectives Identify screening tools and potential results. Based on screening results, develop methods for further evaluation. Identify when specialty referral may be indicated and community resources for referral. Introduce treatment methods for behavioral health problems within primary care.

Katherine Hobbs Knutson, MD MPH khknutso@childrensnational.org Questions? Katherine Hobbs Knutson, MD MPH khknutso@childrensnational.org