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

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

3. 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.

4. 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)

5. 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

6. 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 (TS modifier for at risk screens)

7. 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.

8. Borderline screen
Consider reevaluating in 1 month

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

10. 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.

11. 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.

12. 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.

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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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.

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

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

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

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

24. 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)

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

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

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

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

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

30. 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.

31. Borderline or positive results
Safety issues
Substance abuse
Suicide
Psychosis

32. 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.

33. 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.

34. 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.

35. Borderline or positive results
Safety issues
Substance abuse
Suicide
Psychosis

36. 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.

37. 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

38. Triage decision following a borderline or positive screen

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

40. 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

41. 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) I I Early Stages I T I

42. 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
Web
Phone
Web

43. 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.

44. 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)

45. 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

46. 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.

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

48. 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.

49. Triage decision
Behavior concerns with impact on function

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

53. 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.

54. 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.

55. 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.

56. 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.

57. 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.

58. 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

59. DC Mental Health Resource Guide: DCHEALTHCHECK.NET

61. 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

62. 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.

63. Triage decision Behavior issues with safety concerns
Consider calling CHAMPS ( ) 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

64. 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.

65. 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.

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