Behavioral Health Screening & Referral in Pediatric Clinics Brigette Vaughan MSN, APRN, PMHNP-BC University of Nebraska Medical Center

Setting the stage… Nebraska has 27 “rural” psychiatrists (only 9 see children), 20 psychiatric nurse practitioners, 61 psychologists, and 0 developmental pediatricians. Outside of Omaha and Lincoln, only 4 counties have a child psychiatrist Rural mental health providers are spread over 70,000 square miles and 900,000 lives There are few resources for children and families, as well as schools and primary care providers for managing behavioral health concerns

NAMI Report Card (“Grading the States”, 2006) Infrastructure D- Information Access F Services D Recovery Supports C- Overall grade: D

Updating the System The family physician or pediatrician is often the FIRST person consulted regarding behavioral health issues. They have become “defacto” behavioral health providers. >60% of psychotropic medications are prescribed by primary care providers Many providers surveyed indicate they are not comfortable prescribing these medications

Research has demonstrated that behavioral health issues are “missed” greater than 53% of the time in primary care. The use of behavioral screening tools in primary care can increase recognition and diagnosis of behavioral disorders up to 70%.

LB556 Provides that a trained staff person must be available if a child is receiving telehealth services The trained staff will create a safety plan if a safety threat results during therapy Behavioral health screenings should be offered by physicians during physicals

The Behavioral Health Center of Nebraska will provide training on children’s behavioral health care for educators serving clinics that provide behavioral health screenings (with parental consent) during physicals and offer integrated child psychologist services on site. Right now this includes the Valentine, Omaha Children’s Physicians Dundee, and Columbus areas. These areas are engaged in a pilot integrated clinic program (as set up by LB556) to measure effectiveness of routing screenings

Establishes consultation services for primary care clinicians caring for children with behavioral health issues in integrated pilot site clinics The bill establishes regulations on how the integrated clinics will run, and what data will be collected The bill addresses various reimbursement issues under Title XIX, to include medicaid reimbursements for services provided via telehealth

The Vanderbilt Scale A 55-question assessment tool. It reviews symptoms of ADHD according to the DSM-IV criteria. It also screens for co-existing conditions such as conduct disorder, oppositional-defiant disorder, anxiety and depression, and more.

Current Screening Data Total Screens All Ages (3-18) 1029 Positive 259 (25.2%) All Ages Inattention 10.4% Hyperactivity 8.2% Combined 6.5% Older Children 6-18 Inattention 11% Hyperactivity 7.3% Combined 5.7% ODD 10.6% Conduct 3.5% Anxiety/Depression 6.9% Younger Children 3-5 Inattention 9.0% Hyperactivity 10.0% Combined ADHD 8.3% 143 f/u Calls 51 successful phone contact 34 psychology service referrals/consults 17 declined services 25 NP referrals/consults Negative 770 (74.8%) + screen-met threshold on scale or requested help Psych referral includes recommendations given over phone, already a current patient in psychology or scheduled new appt NP consult includes referrals (primarily Columbus) and phone med consults

Number of Areas Scored Above Cut-off (children 6-18 years)

ADHD Comorbidity Often Complicates the Diagnosis and Treatment of ADHD ADHD alone 31% 31% Oppositional Defiant Disorder 40% Tic Disorder 11% ADHD n=579 Conduct Disorder 14% 38% Anxiety/Mood Disorders Jensen P, et al. Arch Gen Psychiatry 1999;56:1073-1086.

LB556 & School Nurses Integrated care is the goal for behavioral health care in the future. This will reduce stigma, increase access, and reserve more severe cases for psychiatric nurse practitioner and child psychiatrist care. If a school nurse notices a child is exhibiting symptoms of a behavioral health disorder, this condition should be brought to the teacher and parent’s attention using school policy. The parents should then be referred to a primary care clinic for care, preferably one that offers integrated care (psychologist in-house).

Encourage physician colleagues to encourage the use of valid and reliable screening tools in their clinic as a routine part of child physicals. Encourage parents and physicians to refer to child psychologists/behavioral therapists for combined treatment. Reach out to MMI and BHECN for needed educational programs to meet knowledge gaps.

BHECN http://www.unmc.edu/bhecn/ Howard Y. Liu, M.D. Medical Director Behavioral Health Education Center of Nebraska (BHECN) Office Phone:  402-552-7697 Direct Line:  402-552-6338 Pager:   402-888-0464 E-mail: hyliu@unmc.edu Heidi J. Keeler, PhD, RN Asst. Professor, Community Based Health Dept. Nurse Planner, Continuing Nursing Education Director of Educational Design, BHECN Phone: (w) 402-559-4524 Fax: 402-559-4303 E-mail: hkeeler@unmc.edu  For more information regarding CNE opportunities please visit: http://www.unmc.edu/nursing/Continuing_Nursing_Education.htm 

Munroe Meyer Institute   Munroe Meyer Institute Joseph H Evans, Ph.D. Professor, MMI and Pediatrics Associate Clinical Director, Behavioral Health Education Center of Nebraska Munroe-Meyer Institute University of Nebraska Medical Center 402-559-6408

Brigette Vaughan MSN, APRN-BC, NP Nurse Practitioner, Munroe Meyer Institute UNMC Developmental and Behavioral Pediatrics Nurse Coordinator, Department of Psychiatry Child & Adolescent Psychopharmacology Research bvaughan@unmc.edu 402-559-4949 402-552-6239

Questions?