Making a Difference for Children Across North Carolina

School Age and Adolescent Mental Health Risk Factors and Screenings Beth Glueck, MA, LPCS, NCC Licensed Professional Counselor Supervisor Marla Satterfield, MA, LPC, NCC Licensed Professional Counselor

American Academy of Pediatrics policy statement: “Pediatric primary care clinicians have unique opportunities and a growing sense of responsibility to prevent and address mental health and substance abuse problems in the medical home.” -- Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health

Objectives Increase use of screening tools. Improve familiarity with tools. Learn the appropriate response to positive screens.

Who are Children and Youth with Special Health Care Needs (CYSHCN)? “ those who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Defined by the Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).

Prevalence of CYSHCN National 10.2 million children identified in the United States with special health care needs. 16% are not receiving needed services. Majority receive services at physician’s office. North Carolina Over 300,000 children identified as CYSHCN. 14.9% are not receiving needed services % receive care in a medical home.

Child & Adolescent Mental Health Nationally –One in four children experience a mental health condition. North Carolina –NC ranked 32 in the nation for MH services. –61.7% received MH treatment in 2007.

NC Prevalence Rates Children 6 to 11 years of age –ADHD: 40.8% –Depression, Anxiety, and other emotional: 21% Adolescents 12 to 17 years of age –ADHD: 34.8% –Depression, Anxiety, and other emotional: 26.2% –Substance abuse: 11% (illicit drugs) 14.3% (alcohol)

Child & Adolescent Risk Factors Family and community factors –Maternal depression –Domestic violence –Trauma –Parental stress –Poverty –Family history of mental health & substance abuse

Why Use Screening Tools? Annual well visit screening on social and emotional issues leads to: –Prevention –Early Identification of mental health problems –Aid in establishing appropriate assessment plan. –Referral and treatment to needed services. –Recommended by the AAP Task Force on Mental Health (TFOMH)

Why Use Screening Tools? “ Early detection and intervention, particularly in low-income populations, may prevent or ameliorate mental health problems in children and adolescents.” -- The Case for Routine Mental Health Screening Addressing Mental Health Toolkit

Screening Tools Should Be: Validated Reliable Age appropriate Brief Culturally considerate

Screening Tools Should be Used: Annual well visits Any of the following: –Family disruption –Poor school performance –Recurrent somatic complaints –Involvement of DSS or juvenile justice –Behavioral difficulties –School or family reports psychosocial concerns

Recommended Primary Screening Tools School age (6-10) –Pediatric Symptom Checklist (PSC) Adolescent (11-21) –Pediatric Symptom Checklist (with Y-PSC) –Bright Futures Adolescent Questionnaire –Guidelines for Adolescent Preventive Services (GAPS)

Pediatric Symptom Checklist (PSC) Psychosocial screen to identify cognitive, emotional, and behavioral problems for early intervention. Versions: PSC parent completed Y-PSC youth completed (11 & up) Items: 35 Validity: specificity of.68 and a sensitivity of.95 Reliability (test re-test): r=

Pediatric Symptom Checklist (PSC) cont. Positive scores on PSC –Children ages 4 and 5 = 24 and above –Ages 6 through 16 = 28 and above Positive score on Y-PSC –Ages 11 and above = 30 or higher

Bright Futures Adolescent Questionnaire Designed to help busy clinicians prioritize topics to make the most of their time with patients. Optimize visit time, many health care professionals choose to gather information while families and patients are waiting to be seen. Pre-visit Questionnaires help practitioners obtain developmental surveillance information from parents and youth.

Bright Futures cont. Four questionnaires based on developmental maturity: –Older Child/Younger Adolescent –Early Adolescent –15 to 17 Years –18 to 21 Years

Guidelines for Adolescent Preventive Services (GAPS) GAPS is a comprehensive set of recommendations that provides a framework for the organization and content of preventive health services. Recommendations are organized into 4 types of services, which address 14 separate topics/health conditions: –Delivery of health care services –Promotion of health and well-being –Screening for specific conditions common in adolescents and that cause significant problems. –Use of immunizations

GAPS cont. Screening tools are appropriate for 11 to 21 year olds. Three questionnaires available based on developmental maturity: –Younger Adolescent Questionnaire –Middle-Older Adolescent Questionnaire –Parent/Guardian Questionnaire All questionnaires are available in Spanish.

Secondary Screenings Suspected Diagnosis: –ADHD (example: Vanderbilt or Conners) –Depression (PHQ-A, CDI) –Anxiety (PHQ-A, SCARED) –Substance Abuse (CRAFFT)

Patient Health Questionnaire (PHQ-A) Modified for Teens Indicates risk of depression or suicide and is not a diagnosis. Ages: Items: 13 Administration: inform patient of confidentiality and give privacy to complete. Scoring: provides a range of depression risk –A positive response to suicidal ideation or previous suicidal attempt is a positive screen regardless of the overall total score.

The CRAFFT Screen Recommended by the AAP’s committee on substance abuse to screen for high risk alcohol and drug use. Ages: 14 and up Items: 9 Positive score: a “Yes” on 2 or more items.

Positive Scores Are not a diagnosis. Indicate a need for further assessment.

Using Algorithms in Primary Care Developed by AAP Task Force on Mental Health to represent the process primary care providers can utilize for mental health services in the medical home. Algorithm A promotes social-emotional health, identifying mental health concerns or symptoms, child and family involvement in addressing those concerns or symptoms, and triaging for problems that require further assessment or referral. Algorithm B illustrates the process of assessment and ongoing care of children with identified social- emotional, mental health or substance abuse problems.

Algorithm A Visit Scheduled Collect and review pre-visit data Provide initial clinical assessment; observe child-parent interactions. Acknowledge and reinforce strengths

Algorithm A: Is there a concern? Concerns (Symptoms, functional impairment, risk behaviors, perceived problems)? NO YES Provide anticipatory guidance for age per Bright Futures, Connected Kids, or KYSS Return to routine health supervision

Algorithm A: Decision Making Concerns ? YESYES Emergency ? YESYES NO Facilitate referral Provide initial intervention; facilitate referral for specialty services Further diagnostic assessment needed? YES Collect and review data from collateral sources Proceed to Algorithm B

Algorithm B: Assessment Further assessment needed MH/SA concern Who will provide further assessment?

Who Provides Assessment? Interpret findings to family ( and youth as appropriate); convey hopefulness about treatment and recovery Primary Care MH assessment Referral to specialist Collect reports and recommendations Child receiving MH services Who provides assessment?

Is Specialty Care Needed? Facilitate involvement of specialist Specialty care needed? YES Collect reports and/or convene team to review Collaboratively develop a family- centered plan NO Implement chronic care protocol

Is Concern Persisting? Is concern persisting? NO Return to routine health supervision & monitor for further issue s YES Interpret findings to family (and youth as appropriate); convey hopefulness about treatment and recovery. Specialty care needed?

Group Activity

A Physician’s View of Screening D_OcHc&feature=player_embeddedhttp:// D_OcHc&feature=player_embedded

References American Academy of Pediatrics (2010). Addressing mental health concerns in primary care a clinician’s toolkit. Elk Grove Village, IL: American Academy of Pediatrics. American Academy of Pediatrics. (2009).The future of pediatrics: Mental health competencies for pediatric primary care. Committee on psychosocial aspects of child and family health and task force on mental health, Pediatrics, 124, Retrieved from Bright Futures. Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved [03/03/2010] from Drug and alcohol abuse among teens in North Carolina. Retrieved from Rehab- North-Carolina.asp Rehab- North-Carolina.asp McPherson, M., Arango, P., Fox, H.B. (1998). A new definition of children with special health care needs. Pediatrics, 102, Merikangas, K.R.,He, J., Burstein, M., Swanson, S.A., Avenvoli, S., Cui, L., Benjet, C., Georgiades, K., Swendsen, J.( 2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity study-adolescent supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), Sexton, C., Gerald, L., Rager, K.M. (2010). Annual high-quality wellness visits for adolescents: A standard whose time has come. North Carolina Medical Journal, 71(4), State data center, North Carolina. Retrieved from – TeenScreen Capitol Hill Forum: A Physician’s Perspective: Dr. Mason Turner [Video file]. (2010, December 9). Retrieved from