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Integrating Behavioral Health into Pediatric Primary Care for Young Children and Families
Strategies and Lessons Learned from the FieldDeborah F. Perry, PhDDirector of ResearchGeorgetown UniversityCenter for Child and Human Development
OverviewEarly Childhood Mental HealthPolicy ContextSAMHSA-funded study methodsDescription of selected sitesLessons learnedDiscussion
The Context Children are: Being kicked out of child care settings Struggling with the effects of violence Showing the impacts of maternal
depression Dealing with multiple family risks (parental
substance abuse, domestic violence and mental illness)
The New Freedom Commission
Goal 4: “Early Mental Health Screening, Assessment and Referral to Services Are Common Practice”
Quality screening and early intervention in primary care offices and school-based health centers
EPSDT is one vehicle for children and adolescents who are Medicaid eligible to obtain services
Social Emotional Development
Inter-relatedness of domains
Intimately tied to caregivers mental health
Core tasks: Attachment Behavior Competence
Early Childhood Mental Health The social, emotional and
behavioral well-being of young children and their families
The developing capacity to experience, regulate, express emotion
Form close, secure relationships
Explore the environment and learn
Adapted from ZERO TO THREE
Estimated PrevalenceNo national epidemiological data Early Childhood Longitudinal Study:
10% of all kindergarten children show problematic behavior
Rates are two to three times as high in low-income samples
Clinical level problems are lower (4-10%)
Opportunities for Partnership Well-child visits
recommended during first three years of life: 2-3 days, by 1st
month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 3 years. (Medline Plus)
SAMHSA Study Funded jointly by Center for Mental Health
Services, Center for Substance Abuse Prevention, Center for Substance Abuse Treatment and the Office of the Administrator
Focus on infants, toddlers and their families Intersection between infant mental health and
primary/pediatric care
Other National EffortsStarting Early Starting SmartEarly Head StartHealthy StepsABCDMedical Home InitiativeBright Futures Mental Health
Methods Selection criteria:
Medical Home Mental Health and
Substance Abuse Screening Facilitated Referrals
Developmental Screening
Treating the Family as the Unit of Care
Focus on pregnant women, infants and toddlers
Protocol examined range of constructs: Cultural competence Screening tools Financing Lessons learned Barriers Staff development
Multiple interviews and/or site visits
Medical HomeA community-based primary care “medical home” is accessible, family-centered. continuous, comprehensive, compassionate, developmentally appropriate coordinated, culturally competent and accountable.
The Medical Home
Not a place Provision of
preventive care Anticipatory
guidance Early intervention Appropriate use of
sub-specialties
Interaction with community-based organizations: schools, WIC, Head Start
Maintain a central record and data base
24/7 coverage
Sites Selected Beaufort Pediatrics SC Foster Care Pediatrics,
NY Guildford Child Health,
Inc. NC Hagan and Rhinehart
Pediatricians, VT
Healthy Steps for Young Children, CA
High Point Medical & Dental Clinic, WA
Hope Street Family Center, CA
Mary’s Center for Maternal and Child Care, DC
Synthesis of Strategies Medical Home Comprehensive
Screening Developmental Mental Health Substance Abuse
Behavioral Health Services
Facilitated Referrals
Family as Unit of Care
Cultural Competence
Screening Tools For Children:
Parent’s Evaluation of Developmental Status (PEDS)
ASQ/ASQ:SE Pediatric Symptom
Checklist
BITSEA, DECA-C
For Adults: CES-D Edinburgh Postnatal
Depression Scale
CAGE AUDIT 2-question
depression screen
Ages & Stages: SE Children birth thru 60 months Series of 8 parent-completed questionnaires,
6 month intervals 10-20 minutes to complete 4-6th grade reading level Curricular guidance for age-appropriate
activities Developed by Jane Squires, Diane Bricker & Elizabeth
Twombly
ASQ:SE Domains
Adaptive functioning Autonomy Interactions Compliance Coping Self Regulation Communication
Reliability Internal consistency,
overall .82 Test-Retest (3
weeks) 94%
• Validity Sensitivity 78% Specificity 95%
Infant Toddler Social Emotional Assessment ITSEA… BITSEA: 60 items based upon
empirical and clinical concerns Children ages 12-36 months Completed in 10 minutes by adult who knows
child well 4-6th grade reading level 49 “problem” items and 11 “competency”
items Developed by Margaret Briggs-Gowan & Alice Carter
BITSEA Problem Domains
Activity/Impulsivity Aggression/Deviance Peer aggression Depression/Withdrawal General Anxiety Negative Emotionality Maladaptive Atypical
Competencies Social relatedness Imitation/Play Empathy Prosocial peer Attention Compliance
Devereaux Early Childhood Assessment (DECA) Strongly grounded in resilience theory:
identify within-child protective factors Children 2-5 years old Completed by parents or other caregivers Assesses the frequency of 27 positive
behaviors, plus 10 item behavioral concerns screener
DECA-C: clinically significant items
DECAThree domains:
Initiative: use of independent thought or action
Self Control: experience range of emotions and express these appropriately
Attachment: mutual, strong, long-lasting relationship with significant adult
Caregiver Depression In the past year, have you had two
weeks or more during which: you felt sad, blue, or depressed? Lost pleasure in things that you usually
cared about or enjoyed?
CAGE QuestionnaireCut down on drinkingAnnoyance with criticisms about
drinkingGuilt about drinkingEye opener: using alcohol
Lessons LearnedCo-location of services leads to better
integrationMake comprehensive screening routine
pediatric practice Mental Health for parents Substance Abuse for parents Developmental Screening tools for infants
and toddlers
Building LinkagesRelationships with referral sources
crucial Philosophy, approach, cultural competence
Knowledge of range of services offered Eligibility Taking new patients Private/public insurance
Formal versus informal linkages
Ongoing ChallengesBilling and finances
96110, 96111Special populationsSustainability
Grant fundsMacro-level policy climate
New Tools from Bright FuturesSocial Emotional Development
In infancy (birth through 12 months) In Early Childhood (Ages 1-4 years) Parent-focused checklists Domains (e.g., feeding, sleeping) What to Expect When to Seek Help
