1. Session #G3, #
Pediatric Possibilities: An Examination of Integrated Behavioral Health Care for Children and Adolescents
Toni Watt, PhD, Professor of Sociology, Texas State University (San Marcos, TX)
Alejandra Posada, MEd, Chief Program Officer, Mental Health America of Greater Houston (Houston, TX)
Rick Ybarra, MA, Program Officer, Hogg Foundation for Mental Health (Austin, TX)
Please insert the assigned session number (track letter, period number), i.e., A2a
Please insert the TITLE of your presentation.
List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation.
You may acknowledge other authors who are not attending the Conference in subsequent slides.
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Collaborative Family Healthcare Association 18th Annual Conference

2. Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
You must include ONE of the statements above for this session.
CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message.
The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.
Collaborative Family Healthcare Association 18th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
Objective 1. Describe the evidence-base for pediatric IHC programs
Objective 2. Identify several different models of care for children and adolescents at risk of emotional and/or behavioral health problems
 Objective 3. Develop an understanding of unique challenges to (and potential solutions for) implementing and evaluating pediatric integrated behavioral health programs
Include the behavioral learning objectives you identified for this session
Collaborative Family Healthcare Association 18th Annual Conference

4. Bibliography / Reference
Asarnow, J., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated Medical-Behavioral Care Compared with Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatrics, 169(10), doi: /jamapediatrics
Kolko DJ, Campo J, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. (2014). Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics.133(4).
Kolko DJ, & Perrin E. (2014). The integration of behavioral health interventions in children’s health care: services, science, and suggestions. Journal of Clinical Child & Adolescent Psychology, 43(2),
Pires, S., Grimes, K., Gilmer, T., Allen, K., Mahadevan, R., & Hendricks, T. (2013). Identifying Opportunities to Improve Children’s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, Inc. Faces of Medicaid Data Brief.
Richardson LP, Ludman E, McCauley E, et al. (2014). Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA.312(8):
U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau (2012).The AFCARS Report: Preliminary FY 2011 estimates as of July Washington, DC.
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 18th Annual Conference

5. Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
Collaborative Family Healthcare Association 18th Annual Conference

6. Group Exercise
Question: What are some reasons why IHC has not been adopted or is not widespread in pediatric settings? We know how effective IHC is in a variety of settings...
5 minutes small group discussion; select group leader; discuss question, select top three answers in rank order as agreed upon by your group; report out by each group by group leader (30 secs per group)
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

7. Framing of Presentation
The 4Ps: Practice, Programs, Policy and Partnerships (local provider level; health systems; state; national)
Bring forth examples based on the limited literature, implementation efforts, and evaluation findings based on the work done evaluating pediatric IHC programs in Texas
Common themes anchored in the 4Ps of Practice, Programs, Policy and Partnerships
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

8. Evidence base and examples of program
implementation efforts in pediatric IHC
Much variation found in practice
Extent of integration/collaboration
Condition(s) and ages targeted
Recipient of intervention(s) – child and/or parent(s)
Scant evidence base
Lack of rigorous designs with control groups
Small sample sizes, limited measurement & follow-up
Meta-analysis by Asarnow et al. (2015)
Analyzed 31 RCTs
Overall summary effect for intervention vs. usual care was small, statistically significant; wide range of effect sizes for individual studies
Treatment vs. prevention trials
Level/model of integrated care
Condition(s) targeted
Overall summary effect: d=0.32; p<.001
Effect size for individual studies: d ranging from to 2.76
Treatment trials – Small to medium statistically significant effect (d=0.42; p<.001); 66% probability that a randomly selected youth would experience better outcomes after receiving an integrated behavioral health intervention than a randomly selected youth receiving usual care
Prevention trials – Weak, not statistically significant (d=0.07; p = .49
Collaborative care – Medium, statistically significant effect (d=0.63, p<.001); 73% probability that a randomly selected youth would experience better outcomes after receiving collaborative care than a randomly selected youth receiving usual care
Other models – Small, statistically significant effect (d=0.40, p<.001)
Substance use – Weak effect (d=0.17, p=.35)
Mental health – Medium, statistically significant effect (d=0.51, p<.001)
Collaborative Family Healthcare Association 18th Annual Conference

9. Example: The Center for Children and Women
Owned/operated by Texas Children’s Health Plan (Medicaid MCO in Houston, Texas area)
Obstetrics/gynecology and pediatrics, with integrated behavioral health for pediatric patients and pregnant/postpartum women
BH staffing (Greenspoint location, serves ~14,000 patients): 2 social workers (non-licensed), 1 LCSW, 2 LPCs, 1 psychologist, ½ psychiatrist (psychiatric time primarily reserved for complex cases and consultation)
Mental health & substance use services provided; services include individual and family therapy, CBT, motivational interviewing, parent education, assessment of social needs
Accessibility: Pediatrics available 100 hours per week (BH available 80 hours per week)
Communication: Team huddles, no staff offices, Voalte cell phones for texts/calls within building, information sharing via EPIC
Global payment model allows for flexibility in staffing/services
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

10. Evidence base and examples – The 4 Ps
Practice
Wide variation
Adaptation of collaborative care for a pediatric population
Training of PCPs and other providers
Engagement of parent(s)
Selection of EBPs for use with children and parents
Program
Promising approaches…but more study is needed
Need for rigorous studies, including large, diverse trials
Policy
Rigorous studies necessitate substantial funding
Reimbursement & financial sustainability
Availability/accessibility of services
Partnerships
Provider partnerships/collaboration
Parent(s)/family as partners
Consider innovative partners beyond traditional providers – e.g., schools, health plans
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

11. Evaluation: Four Pediatric IHC Programs in Texas
Early Childhood Nutrition Intervention
Pregnancy through 12 month WCC
Early Childhood Intervention to Mitigate Toxic Stress
Age 6-48 months (WCCs)
Integrated Behavioral Health Care Program
School age children/adolescents
Foster/Kinship Care
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

12. Early Childhood Nutrition Intervention
Target
Pregnancy through 12 month WCC
Programming
Vouchers, cooking classes, nutrition and lactation counseling
Evaluation Design
Quasi experimental design-intervention and comparison
Prospective study of pregnancy, 2, 6, and 12 mth WCCs
Outcomes
Diet, depression, stress, weight, infant development (ASQ)
Findings
High program participation
Improvements in diet, depression, and infant development
Large effects-Cohen’s d
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

13. Early Childhood Intervention for Toxic Stress
Target
Age 6-48 months
Programming
Universal messaging, screening for maternal depression, substance abuse, and/or domestic violence, Circle of Security (COS) Attachment Intervention
Evaluation Design
Quasi experimental design-intervention and comparison with propensity matching
Prospective
Outcomes
Parent-Child Dysfunctional Interaction (PSI)
Infant Social and Emotional Adjustment (ASQ:SE)
Findings
Low program participation
Pilot project in progress (evolving)
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

14. Pediatric IHC Target Programming Evaluation Design Findings Age 6-17
On-site and collaborative
Care management, psychiatric consult, therapy
Two sites
Evaluation Design
Pre/Post (3-6 months follow-up)
Outcomes: Vanderbilt (parents and teachers), Phq-9 for older adolescents
Findings
Data collection problems at one site
Errors in Vanderbilt data entry
Only collected Vanderbilts from parents
Medium effects for ADHD (teachers only), large effects for depression
Literature suggests control groups will have small effects
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

15. IHC for Foster/Kinship Care
Target
Age birth to 17
Programming
On-site and collaborative
Care management, psychiatric consult, therapy
Evaluation Design
Qualitative (stakeholders and caregivers)
Pre/Post (3-6 months follow-up)
Outcomes: Child Well-Being (BERS-2)
Findings
Small to medium effects
Care management is key
IHC needs to evolve to address
Early childhood (0-5)
Trauma
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

16. Evaluation: The 4 Ps of Pediatric IHC
Practice
Wide age range-start early
Programming
Explore early childhood interventions
Triple P, COS, VIP, etc.
Program uptake an issue
Policy
Pediatric IHC in its infancy-Evaluation needed
Baseline/comparison group data
Reliable, valid and easy to administer instruments
Qualitative
Effect sizes
Partnerships
IHC team
Program staff, parents, teachers, community agencies
Program staff and evaluators-Assessment and internal evaluation capacity building
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

17. Highlights from small group breakouts at start of presentation
4Ps Revisited
So we heard:
From Ale about the evidence base and examples of program implementation efforts in pediatric IHC & key take-aways related to the 4Ps
From Toni about what has been learned in the evaluation studies of program implementation efforts in pediatric IHC & key take-aways related to the 4Ps
Highlights from small group breakouts at start of presentation
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

18. Q&A/Audience Engagement
Thoughts? Reactions?
Was there anything new presented?
What’s missing from what we covered?
For those working in pediatric settings or child serving agencies, can you share what’s working or not in your setting? What have you learned?
What components are doable and which are not? Why not? What are the barriers that would prevent implementing components or this program?
You can begin your own slides here. Feel free to use your own background on this and subsequent slides.
Collaborative Family Healthcare Association 18th Annual Conference

19. Session Evaluation
Please complete and return the evaluation form before leaving this session. Thank you!
This should be the last slide of your presentation
Collaborative Family Healthcare Association 18th Annual Conference