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
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 [email protected]
Lunch and learn: contact email [email protected]
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,
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.
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 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.
.
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
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
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
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!
