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Teaching Child Psychiatric Assessment Skills: Using Mental Health Screening Instruments Part I Terri Hargrave, MD, MPH SUNY Upstate Medical University

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  • Slide 1
  • Teaching Child Psychiatric Assessment Skills: Using Mental Health Screening Instruments Part I Terri Hargrave, MD, MPH SUNY Upstate Medical University
  • Slide 2
  • Disclosures Dr. Hargrave has no disclosures to make. All screening tools to be discussed are in the public domain.
  • Slide 3
  • Questionnaire and Scenarios with Screens Packet Does everybody have one?
  • Slide 4
  • Todays Goals Practice using screening tools for common pediatric mental health problems Brainstorm how to integrate these tools into participants teaching practices
  • Slide 5
  • Where are these Tools? http://www.capp cny.org
  • Slide 6
  • Public Health Crisis
  • Slide 7
  • 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)
  • Slide 8
  • Public Health Crisis
  • Slide 9
  • Risks (Costello et al. 1999) Adult psychiatric disorders Substance abuse School drop out Impaired peer relationships Difficulties adjusting to work
  • Slide 10
  • Public Health Crisis
  • Slide 11
  • 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)
  • Slide 12
  • Public Health Crisis
  • Slide 13
  • 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)
  • Slide 14
  • Public Health Crisis
  • Slide 15
  • Crisis Approaches Child 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
  • Slide 16
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line Help with referrals Face-to-Face assessments Website CME
  • Slide 17
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line 1-855-227-7272 M-F, 9-5 (except holidays) Liaison Coordinator baseline info Return call from CAP < 2hrs. Follow-up calls encouraged
  • Slide 18
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line Help with referrals Liaison coordinators lists Suggestions for you Follow-up encouraged
  • Slide 19
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line Help with referrals Face-to-Face assessments One time only Your charts prior to FTF Call back to you same day Written report 5 business days
  • Slide 20
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line Help with referrals Face-to-Face assessments Website: Google CAPPCNY Screening tools Links other websites, handouts - Relevant articles
  • Slide 21
  • CAPPC, a CPAP Child Psychiatry Access Program Consult line Help with referrals Face-to-Face assessments Website CME
  • Slide 22
  • CAPPC, a CPAP Child Psychiatry Access Program CME: REACH training 3d course CORE training 4 hours basics Evening webinars - 2 hrs extras Lunch-and-learns on request
  • Slide 23
  • CAPPC, a CPAP Child Psychiatry Access Program Homework #1 Signing up: Fill out the ATP Making that first call: Business card: 1-855-CAPPC72 Cheat Sheet
  • Slide 24
  • 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]
  • Slide 25
  • Screening Four Horses Todays Focus: Screening for the Four Horses of Pediatric Mental Health
  • Slide 26
  • Timeliness: the Medical Home Initiative Screen for MHI at each WCC : PSC-17 Adolescents: Screen for Depression : PHQ9t
  • Slide 27
  • Screen Flavors General, e.g. PSC17, PSC35, SDQ, NOCHSI Adolescent Problem Specific, e.g. Vanderbilt, SCARED, PHQ9, MOAS,
  • Slide 28
  • Where are these Tools? http://www.cappc ny.org
  • Slide 29
  • General Rule Marks on the right mean trouble.
  • Slide 30
  • Slide 31
  • Slide 32
  • Scenario #1 PSC-17 Johnny 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.
  • Slide 33
  • Where are these Tools? http://www.cappc ny.org
  • Slide 34
  • The PSC-17 Valid ages 4-18, Available in many languages Easy to read Quick to fill out
  • Slide 35
  • The PSC-17 Horizontal = Domains: ADHD: Diamonds Internalizing: Squares Externalizing: Circles Vertical = Frequency Never: 0 Sometimes: 1 Often: 2
  • Slide 36
  • Scoring the PSC - 17 Total score = 1(sometimes) + 2(often) Subscale scores: (1)Sometimes + 2(often) for each of the three domains Externalizing (Circles) Internalizing (Squares) ADHD (Diamonds)
  • Slide 37
  • Positive PSC-17 Scores Total score of 15 or more Internalizing: 5 or more Externalizing: 7 or more ADHD: 7 or more
  • Slide 38
  • Johnnys PSC-17 Total score ( 15 ): Internalizing ( 5 Squares ): Externalizing ( 7 Circles ): ADHD ( 7 Diamonds ): Where do we need to probe:
  • Slide 39
  • Johnnys 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
  • Slide 40
  • Probing the Positive PSC-17 Internalizing Disorders Anxiety : SCARED Depression: PHQ9t Externalizing Disorders ADHD: Vanderbilt Behavior Problems: MOAS (SPICY)
  • Slide 41
  • Where to Get These Screening Tools: http://www.cappcny.o rg
  • Slide 42
  • Scenario 2 - Amanda
  • Slide 43
  • 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.
  • Slide 44
  • Amandas mothers PSC17 Score together: Total: ADHD: Internalizing: Externalizing: Needs further attention? If so, where?
  • Slide 45
  • Amandas mothers PSC17 Score together: Total: 5 ADHD: 1 Internalizing: 4 Externalizing: 0 Needs further attention? If so, where? No problem!
  • Slide 46
  • The PHQ9t http://www.cappcny.org
  • Slide 47
  • The PHQ9t First nine items, how often in past 2 wks DSM V criteria for diagnosing Depression Not at all = 0 Several Days = 1 More than Half the Days = 2 Nearly Every Day = 3 Below: Functional Impairment: (should be some) Suicidality (must probe; make safety plan)
  • Slide 48
  • 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
  • Slide 49
  • Amandas PHQ9t #1 Score: Functional Impairment: Suicidality: Interpretation :
  • Slide 50
  • Amandas PHQ9t #1 Score: 9 Functional Impairment: some Suicidality: no Interpretation : mild
  • Slide 51
  • Amandas Interview
  • Slide 52
  • Group Exercise Score Moms PHQ9t
  • Slide 53
  • Mothers PHQ9t Score: Functional Impairment: Suicidality: Interpretation :
  • Slide 54
  • Mothers PHQ9t Score: 3 Functional Impairment: no Suicidality: no Interpretation : negative
  • Slide 55
  • Thinking Through Amanda To treat or not to treat? Treatment options: Counsel and make return visit soon Therapy referral Med management Both therapy and meds
  • Slide 56
  • Amanda comes back and does another PHQ9t What is her score now? Is she feeling functionally impaired? Is she suicidal? Is she in remission?
  • Slide 57
  • 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
  • Slide 58
  • Meet Molly
  • Slide 59
  • Your Next Patient, Molly 7yo 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 moms concerns for ADHD and ask mom to complete a Vanderbilt-parent questionnaire while you do Mollys physical exam..
  • Slide 60
  • ADHD: The Vanderbilt http://www.cappcny.o rg
  • Slide 61
  • The Vanderbilt ADHD Diagnostic Rating Scale Flavors: Parent Initial Follow-up Teacher Initial Follow-up
  • Slide 62
  • Vanderbilt Initial Parent Rating Scale Horizontal: 47 Symptoms in 5 Clusters: Attention Deficit Hyperactivity Oppositionality Conduct Problems Internalizing Symptoms
  • Slide 63
  • Vanderbilt Initial Parent Rating Scale Vertical for Symptom Frequency: Columns Often and Very Often - count as 1 Columns Never & Occasionally - count as 0
  • Slide 64
  • Vanderbilt Initial Parent Rating Scale Performance: items 48-55 Horizontal Domains Academic Social/Classroom Vertical: 5 options 1 = excellent, 2 = Above Avg, 3 = Average, 4 = somewhat of a problem, 5 = Problematic
  • Slide 65
  • Interpreting the Vanderbilt http://www.cappcny. org
  • Slide 66
  • Vanderbilt Cut Points for Significance Parent Questionnaire Symptom Clusters ADD: at least 6 Hyperactivity: at least 6 Oppositionality: at least 4 Conduct: at least 3 Internalizing (Anxiety/Depression): at least 3 Performance/Functional Impairment: any item rated 4 or 5
  • Slide 67
  • More Molly Mollys mother and grandmother and school are all concerned Molly cant sit still while you talk with mom Mom hands you the completed Parents Initial Vanderbilt as you finish Mollys exam. You score the Vanderbilt and then discuss it with mom.
  • Slide 68
  • Mollys Initial Parent Vanderbilt Domain scores: ADD: Hyperactivity: Oppositionality: Conduct: Internalizing: Performance score any 4s or 5s?
  • Slide 69
  • Mollys Initial Vanderbilt Domain scores: ADD 9 Hyperactivity 6 Oppositionality 0 Conduct 0 Internalizing 0 Performance score any 4s or 5s? yes
  • Slide 70
  • 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
  • Slide 71
  • And More Molly Teacher 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
  • Slide 72
  • Table Assignments: Table 1: Teacher baseline Vanderbilt Table 2: Grandmother baseline Table 3: Teacher follow-up Vanderbilt Table 4: Mother follow-up Vanderbilt
  • Slide 73
  • 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
  • Slide 74
  • Anxiety: the SCARED
  • Slide 75
  • Synopsis Scenario 4 Sarah
  • Slide 76
  • Scenario 4: Meet Sarah
  • Slide 77
  • Anxiety the SCARED http://www.cappcny.org
  • Slide 78
  • 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
  • Slide 79
  • Sarahs SCARED Baseline Somewhat Trues: Often Trues: Total Score:
  • Slide 80
  • Sarahs SCARED Baseline Somewhat Trues: 11 Often Trues 24x2=48 Total Score: 59
  • Slide 81
  • SCARED Subscale Scoring Circle the 1s (somewhat) Square the 2s (often) Total = circles + 2(squares)
  • Slide 82
  • Looks Like
  • Slide 83
  • SCARED Subscores
  • Slide 84
  • Sarahs SCARED Baseline cont Panic/Somaticizing: Generalized Anxiety Disorder: Separation Anxiety Disorder: Social Anxiety Disorder: Significant School Avoidance:
  • Slide 85
  • Sarahs SCARED Baseline cont Panic/Somaticizing 12 (positive) Generalized Anxiety Disorder 17 (pos) Separation Anxiety Disorder 8 (pos) Social Anxiety Disorder 14 (positive) Significant School Avoidance 8 (pos)
  • Slide 86
  • Sarahs return 3 months of therapy with no change You start Sarah on sertraline Sarah has now been on med for a month.
  • Slide 87
  • Table Exercise: (1) Total (2) Subscales Table 1: Sarahs SCARED pre meds Table 2: Mothers SCARED pre meds Table 3: Sarahs SCARED on med Table 4: Mothers SCARED on med
  • Slide 88
  • Table Exercise Totals: Table 1: Sarahs SCARED pre meds 59 Table 3: Sarahs SCARED on med 28 Table 2: Moms SCARED pre meds 32 Table 4: Mothers SCARED on med 22
  • Slide 89
  • Table Exercise:(2) Subscale a.) Scores b.) Which meet cutoff Table 1: Sarahs SCARED pre meds Table 2: Mothers SCARED pre meds Table 3: Sarahs SCARED on med Table 4: Mothers SCARED on med
  • Slide 90
  • Table Exercise - Subscales Table 1: Sarahs SCARED pre meds: P 9, G 17, Se 5, So 11, Sc 8 all + Table 3: Sarahs SCARED on med: P 3, G 1, Se 1, So 7, Sc 4 + GAD, school avoidance
  • Slide 91
  • Table Exercise - Subscales Table 2: Mothers SCARED pre meds: P 2, G 14, Se 2, So 8, Sc 6 + GAD, social anxiety, school avoidance Table 4: Mothers SCARED on med: P 2, G 10, Se 0, So 7, Sc 4 + GAD, school avoidance
  • Slide 92
  • Aggression Meet Harry
  • Slide 93
  • Scenario 5: Harry 4yo 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.
  • Slide 94
  • Score Harrys mothers PSC17 ADHD Internalizing Externalizing Total:
  • Slide 95
  • Score Harrys mothers PSC17 ADHD 2 Internalizing 2 Externalizing 12 Total: 16
  • Slide 96
  • More Harry This is the megashot visit and Harry continues to take his anxiety out on his sister. You discover the mom and dad dont 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
  • Slide 97
  • Aggression R-MOAS (SPICY) http://www.cappcny.org
  • Slide 98
  • The MOAS: Retrospective Modified Overt Aggression Scale (SPICY version) Monitoring, not diagnostic, tool 4 subtypes of aggression: verbal, property Self others
  • Slide 99
  • 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
  • Slide 100
  • Harrys Baseline MOAS Subtype scores Verbal: Toward Others: Toward Property: Toward Self: Total score:
  • Slide 101
  • Harrys Baseline MOAS Subtype scores: Verbal 8 Toward Others 40 Toward Property 18 Toward Self 12 Total score 78
  • Slide 102
  • Harrys MOAS after Intervention Subtype scores: Verbal Toward Others Toward Property Toward Self Total score
  • Slide 103
  • Harrys MOAS after Intervention Subtype scores: Verbal 7 Toward Others 12 Toward Property 8 Toward Self 6 Total score 33
  • Slide 104
  • Slide 105
  • 10 minute BREAK Complete Questionnaire and Working Document page 1
  • Slide 106
  • Part II Incorporating Screens in Your Practice
  • Slide 107
  • Reflecting on the Vignettes Who took charge of the screening?
  • Slide 108
  • Slide 109
  • Slide 110
  • Slide 111
  • Slide 112
  • Slide 113
  • 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
  • Slide 114
  • Reflecting on the Vignettes Who Scores the Screen(s)? Receptionist Computer Nurse Doctor Co-Located Mental Health Clinician
  • Slide 115
  • Whole Group Sharing of Experiences What barriers have you encountered in introducing screening tools into your practices? How did you overcome the barriers
  • Slide 116
  • Table Exercise Questionnaire/Worksheet p.2 Each person first steps for your practice Each person shares with others at table while scribe records Spokesperson shares table ideas
  • Slide 117
  • Final Assignment In 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.
  • Slide 118
  • Summary Slide - We: Practiced using screening tools for common pediatric mental health problems Brainstormed how to integrate these tools into participants practices
  • Slide 119
  • Questions?
  • Slide 120
  • Thank you!