teaching child psychiatric assessment skills: using mental health screening instruments part i terri...

Teaching Child Psychiatric Assessment Skills:

Using Mental Health Screening Instruments Part I

Terri Hargrave, MD, MPH

SUNY Upstate Medical University

Disclosures

Dr. Hargrave has no disclosures to make.

All screening tools to be discussed are in the public

domain.

Questionnaire and Scenarios with Screens Packet

Does everybody have one?

Today’s Goals

Practice using screening tools for common pediatric mental health problems

Brainstorm how to integrate these tools into participants’ teaching practices

Where are these Tools?

http://www.cappcny.org

Public Health Crisis

Child Psychiatric Disorders

Prevalence:16-22% (14 million) (Shaffer et al. 1996)

Severe Functional Impairment 9-13% (Center for Mental Health Services 1998)

80% receive no treatment (Surgeon General, 1999)

Public Health Crisis

Risks(Costello et al. 1999)

Adult psychiatric disorders

Substance abuse

School drop out

Impaired peer relationships

Difficulties adjusting to work

Public Health Crisis

Primary Care Providers

Psychosocial problems: Increase from 7% to 19% of all office visits (Kelleher et al. 2000)

85% of all psychotropic meds are prescribed by PCPs (Pediatricians and Family Medicine Physicians.) (Goodwin et al. 2001)

Public Health Crisis

Child Psychiatrists:National need 30,000 in 2000, only 7000

in practice in 2012 (AACAP Work Force Fact Sheet 2012)

Number of child psychiatrists expected to be available by 2020: only 8300 (AACAP Work Force Fact Sheet 2012)

# of pediatricians expected to increase by 60% (Shipman et al. 2004)

Public Health Crisis

Crisis ApproachesChild Psychiatry Access

Programs, e.g.CAPPC

Improve training of Primary Care Clinicians in detecting/managing Mental Health Issues in Pediatric age group

Collocate/Integrate Primary Care and MH

CAPPC, a “CPAP”Child Psychiatry Access ProgramConsult line

Help with referrals

Face-to-Face assessments

Website

CME

CAPPC, a “CPAP”Child Psychiatry Access ProgramConsult line

1-855-227-7272 M-F, 9-5 (except holidays)Liaison Coordinator baseline

infoReturn call from CAP < 2hrs.Follow-up calls encouraged

CAPPC, a “CPAP”Child Psychiatry Access ProgramConsult line

Help with referralsLiaison coordinators listsSuggestions for youFollow-up encouraged

CAPPC, a “CPAP”Child Psychiatry Access Program Consult line

Help with referrals

Face-to-Face assessmentsOne time onlyYour charts prior to FTFCall back to you same dayWritten report 5 business

days

CAPPC, a “CPAP”Child Psychiatry Access Program Consult line

Help with referrals

Face-to-Face assessments

Website: Google “CAPPCNY”Screening toolsLinks – other websites,

handouts-Relevant articles

CAPPC, a “CPAP”Child Psychiatry Access ProgramConsult line

Help with referrals

Face-to-Face assessments

Website

CME

CAPPC, a “CPAP”Child Psychiatry Access Program

CME:REACH training – 3d courseCORE training – 4 hours

basicsEvening webinars - 2 hrs

“extras”Lunch-and-learns – on

request

CAPPC, a “CPAP”Child Psychiatry Access Program

Homework #1

Signing up: Fill out the “ATP”

Making that first call: Business card: 1-855-

CAPPC72Cheat Sheet

Homework #2 – Sign up for at least one CAPPC CME

REACH: Google “CAPPC” website

Evening webinar: Google CAPPC

CORE Training: contact email hargravt@upstate.edu

Lunch and learn: contact email hargravt@upstate.edu

Today’s Focus: Screening for the “Four Horses”

of Pediatric Mental Health

Anxiety

ADHD

Depression

Behavioral Problems

Timeliness: the Medical Home Initiative

Screen for MHI at each WCC : PSC-17

Adolescents: Screen for Depression : PHQ9t

Screen “Flavors”General, e.g. PSC17,

PSC35, SDQ, NOCHSI Adolescent

Problem Specific, e.g. Vanderbilt, SCARED, PHQ9, MOAS,

Where are these Tools?

http://www.cappcny.org

General Rule

Marks on the right mean

trouble.

Troubled Tommy

Scenario #1Johnny Smith is here for his 5-year WCC. When Ms. Smith checks in, the receptionist hands her a clipboard with the PSC-17 to complete in the waiting room. The nurse puts it in the room with her other paperwork.

Where are these Tools?

http://www.cappcny.org

The PSC-17

Valid ages 4-18,

Available in many languages

Easy to read

Quick to fill out

The PSC-17Horizontal = Domains:

ADHD: DiamondsInternalizing: SquaresExternalizing: Circles

Vertical = Frequency Never: 0Sometimes: 1Often: 2

Scoring the PSC - 17

Total score = 1(sometimes) + 2(often)

Subscale scores: (1)Sometimes + 2(often)

for each of the three domainsExternalizing (Circles)Internalizing (Squares)ADHD (Diamonds)

Positive PSC-17 Scores

Total score of 15 or more

Internalizing: 5 or more

Externalizing: 7 or more

ADHD: 7 or more

Johnny’s PSC-17

Total score ( 15 ):

Internalizing ( 5 Squares ):

Externalizing ( 7 Circles ):

ADHD ( 7 Diamonds ):

Where do we need to probe:

Johnny’s PSC-17

Total score ( 15 ): 17

Internalizing ( 5 Squares ): 0

Externalizing ( 7 Circles ): 8

ADHD ( 7 Diamonds ): 9

Where do we need to probe: ADHD and Externalizing

Probing the Positive PSC-17Internalizing Disorders

Anxiety : SCAREDDepression: PHQ9t

Externalizing Disorders

ADHD: VanderbiltBehavior Problems: MOAS

(SPICY)

Where to Get These Screening Tools:

http://www.cappcny.org

Scenario 2 - Amanda

Scenario 2

Amanda is a teen who comes with her mom for a Sports Physical. The receptionist gives Amanda the PHQ9t to complete while mother does the PSC-17.

Amanda’s mother’s PSC17

Score together:Total:ADHD:Internalizing:Externalizing:Needs further attention?

If so, where?

Amanda’s mother’s PSC17

Score together:Total: 5ADHD: 1Internalizing: 4Externalizing: 0Needs further attention?

If so, where? No problem!

The PHQ9t

http://www.cappcny.org

The PHQ9tFirst nine items, how often in past 2 wks

DSM V criteria for diagnosing DepressionNot at all = 0Several Days = 1More than Half the Days = 2Nearly Every Day = 3

Below:Functional Impairment: (should be some)Suicidality (must probe; make safety plan)

Interpreting the PHQ9 score

0-5: No Significant Depression; Remission

5-9: Mild Depression

10-14: Moderate Depression

15-19: Moderately Severe Depression

20 or more: Severe Depression

Amanda’s PHQ9t #1

Score:

Functional Impairment:

Suicidality:

Interpretation:

Amanda’s PHQ9t #1

Score: 9

Functional Impairment: some

Suicidality: no

Interpretation: mild

Amanda’s Interview

Group Exercise

Score Mom’s PHQ9t

Mother’s PHQ9t

Score:

Functional Impairment:

Suicidality:

Interpretation:

Mother’s PHQ9t

Score: 3

Functional Impairment: no

Suicidality: no

Interpretation: negative

Thinking Through Amanda

To treat or not to treat?

Treatment options:Counsel and make return

visit soonTherapy referralMed managementBoth therapy and meds

Amanda comes back and does another PHQ9t

What is her score now?

Is she feeling functionally impaired?

Is she suicidal?

Is she in remission?

Amanda comes back and does another PHQ9t

What is her score now? 1

Is she feeling functionally impaired? no

Is she suicidal? no

Is she in remission? yes

Meet Molly

Your Next Patient, Molly7yo Molly is here for a WCC.

Mother fills out the PSC – 17 in the waiting room and gives it to the receptionist. The receptionist scores it and lets you know that there is a positive screen for ADHD. You probe mom’s concerns for ADHD and ask mom to complete a Vanderbilt-parent questionnaire while you do Molly’s physical exam.

.

ADHD: The Vanderbilt

http://www.cappcny.org

The Vanderbilt ADHD Diagnostic Rating Scale

Flavors:Parent

InitialFollow-up

TeacherInitialFollow-up

Vanderbilt Initial Parent Rating Scale

Horizontal: 47 Symptoms in 5

Clusters:Attention DeficitHyperactivityOppositionalityConduct ProblemsInternalizing

Symptoms

Vanderbilt Initial Parent Rating Scale

Vertical for Symptom Frequency:Columns “Often” and “Very

Often” - count as 1Columns “Never” &

“Occasionally” - count as 0

Vanderbilt Initial Parent Rating Scale

Performance: items 48-55 Horizontal Domains

AcademicSocial/Classroom

Vertical: 5 options1 = excellent, 2 = Above Avg,

3 = Average, 4 = somewhat of a problem, 5 = Problematic

Interpreting the Vanderbilt

http://www.cappcny.org

Vanderbilt Cut Points for Significance Parent QuestionnaireSymptom Clusters

ADD: at least 6Hyperactivity: at least 6Oppositionality: at least 4Conduct: at least 3Internalizing

(Anxiety/Depression): at least 3

Performance/Functional Impairment: any item rated 4 or 5

More Molly

Molly’s mother and grandmother and school are all concerned

Molly can’t sit still while you talk with mom

Mom hands you the completed Parent’s Initial Vanderbilt as you finish Molly’s exam.

You score the Vanderbilt and then discuss it with mom.

Molly’s Initial Parent Vanderbilt

Domain scores:ADD:Hyperactivity:Oppositionality:Conduct:Internalizing:

Performance score – any 4’s or 5’s?

Molly’s Initial VanderbiltDomain scores:

ADD 9Hyperactivity 6Oppositionality 0Conduct 0Internalizing 0

Performance score – any 4’s or 5’s? yes

More Molly

You let mom know you suspect that Molly has ADHD but you need more information before you treat

Mom signs a release of information for school and takes a Vanderbilt home for grandmother to complete.

Your secretary faxes the release and an initial Vanderbilt for the teacher to fax back ASAP

And… More MollyTeacher and Grandmother return

baseline Vanderbilts consistent with ADHD Dx

You start stimulant medication and fax a questionnaire to teacher to fax back after 2 weeks on medication.

Mom and Molly return in 2-3 weeks for follow-up and mom does a Vanderbilt in the waiting room

Table Assignments:

Table 1: Teacher baseline Vanderbilt

Table 2: Grandmother baseline

Table 3: Teacher follow-up Vanderbilt

Table 4: Mother follow-up Vanderbilt

Table Vanderbilt Results:Table 1: Teacher baseline: A:9, H:9, E:0,

I:0, FI: 6

Table 2: Grandma baseline: A:9, H:9, O:0, C:0, I:0, FI:2

Table 3: Teacher follow-up: A:6, H:3, O:0, C:0, I:0, FI:3.5

Table 4: Mother follow-up: A:3, H:1, O:0, C:0, I:0, FI:0

Anxiety: the SCARED

Synopsis Scenario 4 – Sarah

11yo Sarah is coming in because she had trouble sleeping last night. This morning she woke up with a stomach ache so bad that she says she can’t go to school. This is one of many such visits during which the physical exam has been normal. You have known her for a year and you think that anxiety may be “in the driver’s seat.” You ask the front desk to give Sarah and her mom a copy of the SCARED-Child and the SCARED-Parent, respectively to complete while they wait.

Scenario 4: Meet Sarah

Anxiety – the SCARED

http://www.cappcny.org

The “SCARED”: Screen for Child Anxiety Related Disorders

41 Questions on two sides of a page, based on past 3 months

Questions cover 5 Subtypes of Anxiety Disorder

Severity: not (0), somewhat (1) or often (2) true

Total score 25 or higher: positive

Scoring Key on the Back for Subtypes

Sarah’s SCARED Baseline

Somewhat Trues:

Often Trues:

Total Score:

Sarah’s SCARED Baseline

Somewhat Trues: 11

Often Trues 24x2=48

Total Score: 59

SCARED Subscale Scoring

Circle the 1’s (somewhat)

Square the 2’s (often)

Total = circles + 2(squares)

Looks Like

SCARED Subscores

Sarah’s SCARED Baseline con’t

Panic/Somaticizing:

Generalized Anxiety Disorder:

Separation Anxiety Disorder:

Social Anxiety Disorder:

Significant School Avoidance:

Sarah’s SCARED Baseline con’t

Panic/Somaticizing 12 (positive)

Generalized Anxiety Disorder 17 (pos)

Separation Anxiety Disorder 8 (pos)

Social Anxiety Disorder 14 (positive)

Significant School Avoidance 8 (pos)

Sarah’s return

3 months of therapy with no change

You start Sarah on sertraline

Sarah has now been on med for a month.

Table Exercise: (1) Total (2) Subscales

Table 1: Sarah’s SCARED pre meds

Table 2: Mother’s SCARED pre meds

Table 3: Sarah’s SCARED on med

Table 4: Mother’s SCARED on med

Table Exercise Totals:

Table 1: Sarah’s SCARED pre meds 59

Table 3: Sarah’s SCARED on med 28

Table 2: Mom’s SCARED pre meds 32

Table 4: Mother’s SCARED on med 22

Table Exercise:(2) Subscale

a.) Scores b.) Which meet cutoff

Table 1: Sarah’s SCARED pre meds

Table 2: Mother’s SCARED pre meds

Table 3: Sarah’s SCARED on med

Table 4: Mother’s SCARED on med

Table Exercise -Subscales

Table 1: Sarah’s SCARED pre meds: P 9, G 17, Se 5, So 11, Sc 8 all +

Table 3: Sarah’s SCARED on med: P 3, G 1, Se 1, So 7, Sc 4 + GAD, school avoidance

Table Exercise -Subscales

Table 2: Mother’s SCARED pre meds: P 2, G 14, Se 2, So 8, Sc 6 + GAD, social anxiety, school

avoidance

Table 4: Mother’s SCARED on med: P 2, G 10, Se 0, So 7, Sc 4 + GAD, school avoidance

Aggression – Meet Harry

Scenario 5: Harry4yo Harry is here for his PreK physical. Mother filled out his PSC17 in the waiting room in between having to keep Harry from making his 1yo sister scream.

Score Harry’s mother’s PSC17

ADHD

Internalizing

Externalizing

Total:

Score Harry’s mother’s PSC17

ADHD 2

Internalizing 2

Externalizing 12

Total: 16

More HarryThis is the “megashot” visit and Harry

continues to take his anxiety out on his sister.

You discover the mom and dad don’t agree on discipline for Harry

You opt to bring mom back with dad (if possible) and without the kids.

On the return visit, mom fills out the R-MOAS

Aggression – R-MOAS (SPICY)

http://www.cappcny.org

The MOAS: Retrospective Modified Overt Aggression

Scale (SPICY version)

Monitoring, not diagnostic, tool

4 subtypes of aggression: verbal,property Selfothers

The MOAS: Retrospective Modified Overt Aggression

Scale (SPICY version)

Frequency of behaviors during past week

Scores in boxes already weighted by both frequency and severity of subtype

Harry’s Baseline MOAS

Subtype scoresVerbal:Toward Others:Toward Property:Toward Self:

Total score:

Harry’s Baseline MOAS

Subtype scores:Verbal 8Toward Others 40Toward Property 18Toward Self 12

Total score 78

Harry’s MOAS after Intervention

Subtype scores:VerbalToward OthersToward PropertyToward Self

Total score

Harry’s MOAS after Intervention

Subtype scores:Verbal 7Toward Others 12Toward Property 8Toward Self 6

Total score 33

10 minute BREAKComplete

Questionnaire and Working Document

page 1

Part II

Incorporating Screens in Your Practice

Reflecting on the Vignettes

Who took charge of the screening?

Reflecting on the Vignettes: Who gives out the Screen(s)

Receptionist on arrival

Nurse after vitals

Doctor during encounter

Receptionist at exit

Doctor, nurse, receptionist mails/faxes to school

Combination

Reflecting on the Vignettes – Who Scores the Screen(s)?

Receptionist

Computer

Nurse

Doctor

Co-Located Mental Health Clinician

Whole Group Sharing of Experiences

What barriers have you encountered in introducing screening tools into your practices?

How did you overcome the barriers

Table ExerciseQuestionnaire/Worksheet p.2

Each person first steps for your practice

Each person shares with others at table while scribe records

Spokesperson shares table ideas

Final AssignmentIn light of whole group report,

make any adjustments to your individual plan

Turn in Questionnaires, Work Document and Consent Form.

We will email them back to you within the week.

Summary Slide - We:Practiced using screening

tools for common pediatric mental health problems

Brainstormed how to integrate these tools into participants’ practices

Questions?

Thank you!