We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an

unapproved/investigative use of a commercial product/device in this presentation.

Preventive Services Improvement Project

Implementing Bright Futures For Early Childhood:

Partnering with Parents & the CommunityMarian Earls, MD

Paula Duncan, MD

Preventive Services Improvement Project Learning Session

January 21-22, 2011

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West Reading, PAAll About Children

Pediatric Partners PC

Boston, MAChildren’s Hospital Primary Care Center

St Louis, MODanis Pediatrics

Ft Washakie, WYWind River Service Unit

Southern Pines, NCSandhills Peds

Brooklyn, NYLutheran Family

Health Ctr

Hurst, TXCook Children’s

Physician Network

San Antonio, TXCommunity Medicine

Associates

Warrington, PAKressly Pediatrics

Lorton, VAAll Pediatrics

Iowa City, IAU of Iowa

Dept of Peds

Charlotte, NCCMC Myers

Park Pediatrics

Redwood City, CAFair Oaks

Children’s Clinic

Merritt Island, FLAtlantic Coast Pediatrics

Hays, KSHays Med

Pediatric Ctr

Philadelphia, PARoxborough Peds

Williston, NDComprehensivePediatric Care

Haverstraw, NYHaverstraw Peds

Tucson, AZSan Xavier Clinic

Milwaukee, WI16th Street CHC

Appleton, WIChildren’s Health Ctr@ St Elizabeth Hosp

Thanks to our 21 PreSIP Teams!

What We Know

Impact of experience on brain development.

Growth, development, and behavior are inextricably linked.

Emotional development occurs in the context of a relationship (bonding, attachment, reading cues).

Role of Experiencein Early Brain Development

Activation of genes and gene productsInteraction with genetics to determine

morphological and functional brain organization

Requirement for brain development to be normal

Critical and sensitive periods

•Physiological responses to stress in the infant’s environment affect the infant’s social-emotional development.

•The activation of the physiologic stress response system results in increased levels of stress hormones.

•Persistent elevation of cortisol, can disrupt the developing brain’s architecture in the areas of the amygdala, hippocampus, and prefrontal cortex (PFC), and therefore ultimately can impact learning, memory, and behavioral and emotional adaptation.

Toxic Stress

Prevalence and Risk

About 16% of children have disabilities including speech

and language delays, mental retardation, learningdisabilities and emotional/behavioral problems.

____________

(Only 30% are detected prior to school entrance.)____________________

Prevalence and Risk

13% of preschool children have mental health problems.

This rate increases with the co-occurrence of other risk factors:

PovertyMaternal depressionSubstance abuseDomestic ViolenceFoster care

Poverty

Severe child hunger associated with:Increased rates of internalizing behavior

problems in preschoolers and school-age children.

Increased rates of anxiety and depression at school age.

(U Mass Med study 2002)

Foster Care

Children of “risky families,” who have characteristics of conflict, aggression, relationships that are neglectful.

“Risky” environment disruptive of biological stress-response regulatory systems, and to psychosocial functioning.

Impact of Maternal Depression

Infants are at risk for insecure attachment. Children with insecure attachment are more likely to have behavior problems and conduct disorder.

Maternal depression in infancy is predictive of cortisol levels in preschoolers, which is linked with anxiety, social wariness and withdrawal

When mothers experienced major depression, then attachment disorders, behavior problems, and depression and other mood disorders can occur in childhood and adolescence

Disparities

Minorities receive about ½ as much outpatient mental health care as whites.

Most children who need a mental health evaluation do not receive services, and Latinos and uninsured children have especially high rates of unmet needs.

Limited access to mental health services for parents (often underinsured/uninsured)

Disparities

Children in living in poverty have twice the rate of mental health problems as the general population of children.

Rates of use of mental health services are extremely low among preschool children.

Disparities

System CapacityWorkforce shortage of child and adolescent

psychiatrists and clinicians who can work with children.

Even greater workforce shortage of child psychiatrists and psychologists who can work with very young children.

Shortage of mental health providers who can treat the mother-infant dyad

National Perspectives onHealthy Development in Young Children

AAP: new Bright Futures guidelines

AAP: new priority in strategic plan-early brain development

AAP: Task Force on Mental Health & COPACFH

AACAP: Collaborative Mental Health Care Partnerships in Pediatric Primary Care

ABCD (Assuring Better Child Health & Development) Projects: early childhood social-emotional development and mental health

Bright Futures, the AAP, and Health Reform

Coverage of Preventive Services under section 2713 of ACA, July 19, 2010

All private health plans must cover, without cost-sharing all services described in Bright Futures: Guidelines for Health Supervision of Infants Children and Adolescents, 3rd Edition, as of Sept 23, 2010.

Issues: grandfathered plans, language does not include Medicaid plans.

AAP is directly advocating with Secretary Sibelius on these issues.

AAP: Task Force on Mental Health & Committee on the Psychosocial Aspects of Child & Family Health

Chapter Action Toolkit, 2008The Future of Pediatrics: Mental Health

Competencies for Pediatric Primary Care, PEDIATRICS, 124(1), July 2009.

Supplement to Pediatrics (June, 2010)Addressing Mental Health Concerns in Primary

Care: A Clinicians Toolkit (July, 2010)Incorporating Perinatal and Postpartum

Depression Recognition and Management into Pediatric Practice (November 2010)

Addressing Social Emotional Morbidity (pending)

AAP Defines Medical Home

AccessibleFamily-CenteredContinuousComprehensive CoordinatedCompassionateCulturally competent

Medical Home also means…

Caring for the whole child

Considering physical, developmental and mental health together

“not separating the head from the body”

Bright Futures

Health Promotion Themes include: Promoting Family Support Promoting Child Development Promoting Mental Health Promoting Healthy Weight Promoting Healthy Nutrition Promoting Physical Activity Promoting Oral Health Promoting Healthy Sexual Development & Sexuality Promoting Safety & Injury Prevention Promoting Community Relationships & Resources

Bright Futures

1994 1996 1998 2000 2001 2002 2003+

Pfizer Partnership

BF in Practice

Oral Health

BF Pocket Guide

Encounter Forms for Health

Professionals and Families

Anticipatory Guidance

Cards

BF II

BF II Pocket Guide

Encounter Forms for Families II

BF in Practice Nutritio

n

Family Tip

Sheets

BF in Practic

e

Physical

Activity

BF in Practic

e Mental Health

& Toolkit

1990: Initiated by MCHB & Medicaid

NCEMCH 1995: Building Bright Futures AAP

Evaluation&

State Case

Studies

Guidelines

Bright Futures Implementation

2004 2007 2008 2009 2010

BF Periodic Survey #56

BF Pocket Guide

BF

EQIPP Module

BF Perform

Prev. Serv

BFTIBF

NutritionBF

Activity Book

2011 2012

BF

National Fam. Org

Mtg

BF

VDH Web Site

ACA

BF

PreSIP

State of WI

Brightening Oral Health Healthy

Active Living for Families

2000 & 2002

…is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.

Periodicity Schedule

We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an

unapproved/investigative use of a commercial product/device in this presentation.

Example: Example: 18 month 18 month

oldold

We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an

unapproved/investigative use of a commercial product/device in this presentation.

Context

The 18-month-old requires gentle transitions, patience, consistent limits, and respect. One minute he insists on independence; the next minute he is clinging fearfully to his parent.

We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an

unapproved/investigative use of a commercial product/device in this presentation.

Who has an 18 month old?

ANTICIPATORY GUIDANCEEncourage your toddler’s language development by reading and singing to her, and by talking about what you both are seeing and doing together.

Books do not have to be “read.” Talk about the pictures or use simple words to describe what is happening in the book.

Do not be surprised if she wants to hear the same book over and over.

Use simple, clear phrases to give your child instructions.

SAMPLE QUESTIONSHow does your child communicate what she wants? Who or what does she call by name? What gestures does she use to communicate effectively? For example, does she point to something she wants and then watch to see if you see what she’s doing? Does she wave “bye-bye”?

The development of language and communication during the early childhood years is of central importance to the child’s later growth in social, cognitive, and academic domains. Communication is built upon interaction and relationships. Health care professionals have the opportunity to educate parents about the importance of language stimulation, including singing songs, reading, and talking to their child.

Parents may ask health care professionals about the effects of being raised in a bilingual home. They may be reassured that this situation permits the child to learn both languages simultaneously.

LANGUAGE PROMOTION/HEARINGEncouragement of language, use of simple words and phrases, engagement in reading/singing/talking

Bright Futures is the health promotion/disease prevention part of

the medical home

At the heart of the medical home is the relationship

between the clinician and the family or youth

Opportunities for Prevention and Promotion in Primary Care

Prenatal VisitsPsychosocial and maternal depression

screeningDevelopmental & behavioral screening and

surveillance in pediatric and family practice offices

Social/emotional screening for children identified “at risk”

Implementation requires a QI approach to office

process

Mental Health Competencies

The “primary care advantage”Longitudinal, trusting relationshipFamily centerednessUnique opportunities for prevention &

anticipatory guidanceUnderstanding of common social-emotional &

learning issues in context of developmentExperience in coordinating with specialists in the

care of CSHCNFamiliarity with chronic care principles & practice

improvement

Talking with Families

Identify child and parent’s strengths Discuss developmental issues Discuss transition stages Share Information Discuss community resources

PreSIP: Implementing Bright Futures in Early Childhood

Maternal Depression ScreeningBMI Oral HealthDevelopmental ScreeningAutism ScreeningEliciting parent concerns and strengthsCommon factors approachAnticipatory Guidance

PreSIP: Practice Systems

Office Systems InventoryPreventive Services Prompting SystemRisk StratificationFamily InvolvementPromoting Family’s Experience of CareCommunity Linkages