1. Adolescent Screening Stacey Cobb, MD Developmental-Behavioral Pediatrics Assistant Professor of Pediatrics University of South Carolina School of Medicine

2. Disclosures No actual or potential conflicts of interest in relation to this program or presentation. No discussion of off-label pharmacotherapy or devices.

3. Objectives Discuss the role of the Primary Care Provider in adolescent screening Review the administration and interpretation of the most widely used screening tools Develop action steps for positive screen results Discuss barriers in various practice settings

4. Prevalence 11-20% of U.S. children at any given time – Behavioral or emotional disorder 37-39% diagnosed with a behavioral or emotional disorder by 16 years of age – Disruptive behavior – Anxiety – Mood disorders

5. Leading Causes of Limitation due to Chronic Conditions in US Children 1.Speech problems 2.Learning disability 3.ADHD 4.Other emotional, mental and behavioral problems 5.Other developmental problems 6.Asthma or breathing problems

6. Current State of Care Clinicians in more that 200 practices surveyed 50.2% of providers never used standardized measures to assess mental health Fewer than 7% of providers used standardized measures more than 50% of the time

7. Bright Futures Recommendations Structured early developmental screening Annual screening starting at 11 years old – Alcohol & Drug Use/Abuse – Depression Fulfills EPSDT requirement for routine psychosocial screening

8. Substance Abuse Leading cause of morbidity and mortality in adolescents and young adults Risk-taking behaviors and injuries related to substance use is common Adolescents with increased vulnerability to addiction due to the developing brain Although common, use should not be condoned or trivialized

9. Alcohol & Substance Abuse CRAFFT – Use up to age of 21 – Interview or self-report questionnaire Without a parent or guardian present – 4-9 questions depending on answers – Score of 2 or higher identifies a problem Sensitivity of 76%, specificity of 94%

10. Alcohol & Substance Abuse CAGE-AID – 16 years old and up – Interview or self-report questionnaire – 4 questions – Score of 1 or higher is a positive screen Sensitivity of 79%, specificity of 77%

11. Action Plan for Substance Abuse Screening Brief positive feedback for smart decisions Brief advice for substance users – Clear advice to stop and educational counseling Motivational interviewing for problem users – Behavior change or referral to treatment Local mental & behavioral health services Adolescent substance abuse services

12. Depression 2.6 million adolescents (12-17 years old) with 1+ major depressive episode in the past year – 10.7% of the US population in that age range Increased risk of death by suicide Long-term associations – Early pregnancy, decreased school performance, impaired work, social & family functioning

13. Depression Screening Tools Center of Epidemiologic Studies Depression Scale - Revised – Updated for DSM-5 – Description 20 questions Scored on a Likert scale 16 or higher is considered depressed – Acceptable psychometric properties Differences between genders and cutoff values

14. Depression Screening Tools Other tools with less evidence for use – 2 Question Screen – Mood & Feelings Questionnaire – Strengths & Difficulties Questionnaire

15. Anxiety Lifetime prevalence in children & teens is between 8-27% 29% lifetime prevalence with the majority having onset in childhood or teen years Only 40% seek treatment within 1 year Early onset (<13 yo) more likely to be chronic

16. Anxiety Screening Tools SCARED – Screen for Child Anxiety Related Disorders – Parent and self report 8-11 year olds may need explanation – 41 questions – Subscales Generalized anxiety disorder Separation anxiety Social anxiety disorder Panic disorder School avoidance

17. Anxiety Screening Tools Spence Children’s Anxiety Scale – Parent & self report Starting at age 8 – 45 questions – Subscales Panic Social phobia Separation anxiety Generalized anxiety Obsessions/compulsions Fear of physical injury

18. Broad Social Emotional Screens Beck Youth Inventories of Emotional and Social Impairment – Well-studied across demographic groups – Self-report for 7-18 year olds – Depression, anxiety, anger, disruptive behavior, and self-concept – 100 questions (20 for each domain) Pricing – $10 for complete inventory – $2.25 for individual inventories

19. Broad Social Emotional Screens Pediatric Symptom Checklist (17 or 35) – Full and abbreviated forms for parents Full version with subscales – Attentional, internalizing and externalizing problems – Youth self-report >10 years old – Functional impairment items – Different cutoff values for various forms and ages – Pictorial version available – Sensitivity 80-95%, specificity 68-100% (35)

20. Broad Social Emotional Screens Strengths & Difficulties Questionnaire – Youth self-report from 11-17 yo – Parent report for ages 4 through 17 – 25 questions with impact supplement 5 subscales Emotional, conduct, hyperactivity/inattention, peer relationships, prosocial behavior – >80 languages – Sensitivity 63-94%, specificity 88-96%

21. ADHD 4-12% prevalence worldwide 8-11% in the United States Male predominance Inattentive type can be particularly subtle

22. ADHD Screening Vanderbilt ADHD Diagnostic Rating Scales – Most widely used – Teachers are very familiar – Based on DSM criteria – Functional impairment scale – Brief screen for ODD, conduct disorder, mood symptoms

23. ADHD Screening Use of total score for trending response to therapy – Add individual scores from questions 1-18 – Total possible is 54 – More sensitive trending rather than symptom scores alone

24. Action Plan Evidence-based therapies – CBT for mood disorders – Parent-Child Interaction Therapy for behavioral disorders in younger kids – Triple P Pharmacological therapy – Primary care providers – Mental/behavioral health providers Frequent follow up until stabilized

25. Psychosocial Screens 1 in 5 children were living in poverty in 2010 – High risk for behavioral and emotional problems Parental surveys – WE-CARE – Family Psychosocial Screen – Survey of Well-Being in Young Children – Adverse Child Experience Score

26. Action Plan for Psychosocial Screens If you ask, they will tell… Social worker Need knowledge of community resources – Food banks – Shelters – Safety plans

27. Barriers Only 23% of primary care clinicians use standardized screening tools Time constraints (cited by 82% of PCP’s in 1 study) Competing clinical demands Cost burden Staff requirements Lack of consensus on tools Insufficient training and expertise

28. Implementation AAP Task Force on Mental Health – Toolkit to aid implementation efforts Implementation steps – Ready the practice – Identify resources – Establish office routines for screening – Track referrals – Seek payment – Foster collaboration

29. Reimbursement 96110 – developmental testing, limited – Multiple units can be billed – Not covered by some private insurance providers Reimburses for review and interpretation of the screening tool

30. Resources AAP Mental Health Resources – www.aap.org/en-us/advocacy-and-policy/aap- health-initiatives/Mental-Health/Pages/Key- Resources.aspx www.aap.org/en-us/advocacy-and-policy/aap- health-initiatives/Mental-Health/Pages/Key- Resources.aspx Caring for Children with ADHD: A Resource Toolkit for Clinicians – National Initiative for Child Healthcare Quality (www.nichq.org)www.nichq.org

31. References Slomski A. Chronic mental health issues in children now loom larger than physical problems. JAMA. 2012;308(3):223-225. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics. 2006; 118(4): 1808-1809]. Pediatrics. 2006; 118(1): 405-420. Brown RL. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal. 1995:94(3) 135-140. Dhalia S. A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Curr Drug Abuse Rev. 2001:4(1):57-64. Levy, SJL. Committee on Substance Abuse. Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians. Pediatrics.2011;128:e1330–e1340. Weitzman C. Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society of Developmental and Behavioral Pediatrics. Promoting Optimal Development: Screening for Behavioral and Emotional Problems. Pediatrics. 2015;135: 384-395. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Williams, SB. Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventative Services Task Force. Pediatrics. 2009;123:e716-35.