Transcript The School Function Program: A Primary Care Approach

The School Function Program:
A Primary Care Approach to Addressing
Mental Health Problems in School-Aged Children
Alice Kuo, MD, PhD
Med-Peds Rounds
October 13, 2010
Med-Peds Well-Child Care
Series
• School-Aged Children
– Goal of K-12 is to graduate from high
school and go to college or get a job
– Predictors of dropout include poor
academic performance, lack of
engagement with school life
– Mental health issues contribute to both
Background
• Early social-emotional experiences affect brain architecture and
development of young children (IOM, 2000)
• 10-14% of children 0-5 years experience social-emotional
problems that interfere with functioning (Egger 2006; Brauner
2006)
• 21% of children and adolescents meet diagnostic criteria for a
mental health disorder and have evidence of impairment (Shaffer
1996; DHHS 1999)
• 16% of children and adolescents do not meet criteria for a
disorder but have some impairment (Wolraich 1996)
• 50% of adults with a mental health disorder had symptoms by the
age of 14 years (Kessler 2005)
The Problem
• Only 20% of children who need mental
health services receive them
• Why is this?
– Shortage and inaccessibility of parenting
programs
– Shortage of specialty services
– Shortage of school-based mental health
services
– Worse for minority populations
The Consequence
• Vision of Pediatrics Task Force predicts
that mental health care will constitute
30% or more of general pediatric practice
• Primary care clinicians’ role in mental
health care will differ substantially from
specialists
– PCCs will have to elicit psychosocial and
mental health concerns from children
presenting with challenging behavior, chronic
somatic complaints or acute physical
complaints
Unique Strengths of PCCs
• Longitudinal, trusting and empowering therapeutic
relationship with children and family members
• Family-centered of medical home
• Unique opportunities to prevent future mental health
problems through promoting healthy lifestyles
• Understanding of common social, emotional and
educational problems in the context of a child’s
development and environment
• Experience working with specialists to coordinate care
• Familiarity with chronic care principles and practice
improvement methods
Barriers to Primary Care
Change
• Discomfort with knowledge and skills
• Time constraints
• Poor payment
• Limited access to mental health
consultation and referral resources
• Administrative barriers in insurance plans
History of School Function
Program at VFC
• November 2005—Tuesday afternoons at MVG
clinic
– September 2006 social work intern rotated through
– March 2007 physician assistant rotated through
• February 2009—Obtained funding to hire parttime social worker
• September 2009—first social work intern
• January 2010—first MS3 preceptorship
• July 2010—added case manager
• September 2010—second social work intern
• October 2010—SFP moves to Simms peds clinic
• January 2011—second MS3 preceptorship
SFP Stats
• Over 230 cases
• Referrals come from pediatricians, parents,
teachers, and school personnel
• Developing relationships with many schools in
West Los Angeles (LAUSD), SMMUSD, CCUSD,
Inglewood USD (*We have communicated and
worked with over 70 schools within the West LA
region)
• Community Partners: Westside Children’s Center,
Edelman Mental Health Clinic, St. John’s Child
Development Center, among others
Reasons for Referrals
• History of school failure (46%)
• Behavioral problems (46%)
• Inability to do homework (38%)
• Problems paying attention (36%)
• Family dysfunction (12%)
• Mental health issue (6%)
Why School Function?
• Our goal is to address mild to moderate mental
health issues which are hindering a child’s
academic success
• Mental health issues are still a stigma
• Culturally, Latino parents do not seem to
associate mental health issues and school
performance
• Latino parents are invested in their children doing
well in school
Approach to a
School-Aged Child
• Don’t forget: DDS SHAVES mnemonic
DDS SHAVES
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Diet
Elimination
Sleep
Development
Home
School
Safety
Vaccines
Anticipatory Guidance
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Development
Diet
Sleep
Safety
Home
Anticipatory Guidance
Vaccines
Elimination/Encopresis
/ Enuresis
• School
Approach to a
School-Aged Child
• Don’t forget: DDS SHAVES mnemonic
• BUT ask more about what is going on in
school:
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Not just favorite subjects, but GRADES
Friends? Loner? Bullies?
Likes or doesn’t like school? Why?
Teachers
After-school activities
Homework
Screening Questions
for Parents
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Do you have concerns about how your child is
learning in school?
Do you have concerns about your child’s behavior
in school?
Do you have concerns about how your child gets
along with others at school?
Do you have concerns about completing
homework?
Has teacher expressed concerns about your child?
Is your child at risk for repeating school year?
Is your child getting D’s and/or F’s?
Does your child have 2 or more C’s?
**If “yes” to any of the above, consider referral to SFP
Referring Patients into SFP
• Complete SFP Referral Form
• Ask parents to sign “SFP Release of
Information”
• Give Vanderbilts if applicable
• Request a follow-up SFP appointment in 23 weeks
School Function Program Social Work
SFP Screener
Initial Contact (Positive SFP Screen):
* Complete SFP referral form for SFP Clinic Slot
* Social Work/case management will engage
family:
- Introduction to SFP services
- General Intake of school problem
- Psychoeducation & Community Resources
- Plan for follow-up
- Summary to referring physician
Forms to be completed:
* SFP referral form
* Release of information
* Vanderbilt if applicable
* Schedule return visit to SFP Clinic (2 weeks)
SFP Clinic Visit SFP:
•Case consult with SFP social work
* SFP Physician Intake & Diagnostic
Differential
* Review of clinical documents & information:
Vanderbilts, IEP, Evaluations, School
Records Reports & Observations
* School consultation if needed.
Initial Contact for general psychosocial issues :
* Social Work/case management will engage
family:
- Introduction to VFC & community services
- Brief assessment (Anxiety, Depression,
Behavioral & Social)
- Psychoeducation
- Referral information
- Summary of plan with referring physician
Referral to community mental health:
• Venice Family Clinic 3rd floor mental health & social services
• Saint John’s Child & Family Development Center
• Didi-Hirsch Mental Health Counseling Center
• Family Services & Vista Del Mar
• Edelman Los Angeles County Mental Health
• School based mental health
* Psychoeducation regarding Diagnosis &
Intervention Plan
Standard follow-up by pediatric physician at VFC.
SFP 2 month follow –up & continued case management.
SFP visits at Simms
• Starting October 1, two slots per afternoon for #349 (M,
Th, F) have been converted to SFP slots; staffed by
residents, extra time allowed
• On Mon PM, social work intern will be available to provide
support
• On Th, F PM, case manager will be available to provide
support (can be there in Med-Peds on Fridays)
• For Tuesday clinic, make the referrals and have forms filled
out and Sandra will pick up the referrals on Thursday
SFP Clinic Visit
• SFP residents will be synthesize information from SFP social
work intern or case manager
• Differential diagnosis for academic difficulties
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Developmental disability/mental retardation
Learning disorder/disabilities
Attentional issues
Mental health issues
Family dysfunction
• SFP residents will contribute medical aspects which may
affecting academic performance
• Together, SFP residents and SFP social work intern/case
manager will come up with action plan (next steps)
SFP Screener
SFP Clinic
Intake or Follow-Up
Developmental
* PDD
* Autism
* Aspersers
* Delayed Milestones
Intervention
Westside Regional Ctr
Special Education?
IEP/ School Eval?
Home visit
Parent education
Case Management
ADHD/ADD
* Inattentive subtype
* Hyperactive/Impulsive
Subtype
* ADHD Combined
Intervention
Vanderbilts (2x)
Direct Observation
Teacher/School Report
IEP/School Eval?
Home Visit
Rx
Case Management
Learning Disability
* Dyslexia
* Dysgraphia
* Dyspraxia
* Auditory and/or Visual
Processing Disorder
* Dyscalculia
Intervention
Westside Regional Ctr
IEP/School Eval
Special Education?
Accommodations
Home visit
Parent education
Teacher /School Report
Case Management
Psych
* Anxiety
* Depression
* Behavioral
* Oppositional Defiant
* Family Psych Issues
Social
* Child Abuse
* Domestic Violence
* Financial
* Family Stressors
Intervention
3rd floor referral
Community Mental
Health
School Therapy Services
DCFS
SFP:
Brief Tx (5 sessions)
Parent Education
Case
Clarence is 2 years 3 months and does
not speak. In addition, Mom reports
that he has behavioral problems such
as head banging and holding the
saliva in his mouth until he drools.
He tends to play by himself rather
than with other children or even his
5 year old brother.
Autism Spectrum Disorder
• 2007 CDC MMWR report stated that the
prevalence of autism was 1:150 and 1:90 boys
• 2009 NSCH study reports 1:90 (1% of U.S.
children) and 1:50 boys
• 10-25% of children “lose” their ASD diagnosis
• Some studies suggest that the “epidemic” of
autism could be influenced by broadening of
diagnostic criteria
Diagnosis of Autism
Delays or abnormal functioning in one
of the following three areas, with
onset of symptoms prior to age 3
years
A. social interaction
B. language as used in social
communication
C. symbolic or imaginative play
Regional Center
• 1977: Lanterman Developmental
Disabilities Act
• California Department of
Developmental Services (DDS)
contracts with 21 Regional Centers
(private, non-profit)
• IFSP, ITP
Case
Her parents bring 8-year-old Maya to you in clinic
for well-child visit. When asked about school, her
parents state that Maya makes average grades in
second grade and behaves well in class, although
her teachers state that she is a bit of a
“daydreamer.” When you give her the book and
ask her to read a page, you realize that she
struggles to sound out words. Her parents state
that she still cannot read and needs their help to
complete homework.
ADHD DSM-IV criteria
• 6 out of 9 possible symptoms of inattention
• 6 out of 9 possible symptoms of hyperactivity/impulsivity
• Some symptoms present before age 7 years
• Impairment from symptoms present in 2 or more settings
• Clear evidence of clinically significant impairment in social,
school or work functioning
• Symptoms not due to PDD, schizophrenia or other psychotic
disorder
NICHQ Vanderbilt Parent and
Teacher Assessment Scales
• Developed specifically to screen for
DSM criteria
• Scoring is relatively straightforward
• This is meant to be additional
information to help pediatricians
make a diagnosis; not meant to
replace clinical judgment
Stimulant Medications
• Most studied medication in pediatric population
• Relatively safe with predictable side effects
– Difficulty sleeping; insomnia
– Decreased appetite; weight loss
– Vague abdominal symptoms
• Short-acting, may use longer acting or repeat dosing
• Only needed as long as child needs to concentrate or focus;
drug holidays
• Not necessarily forever; could be only as long as until child
is able to manage inattention behaviorally
Case
• Jimmy is an 8 year old in 3rd grade at Main
Avenue Elementary School. He made B’s
and C’s in 1st and 2nd grade, but for the
first semester of 3rd grade has made D’s
and F’s. At the parent-teacher
conference, his teacher informs his
parents that he is not completing his
homework and is unable to answer
questions on tests. What more
information do you want to know and
what do you think might be going on?
What is a “Learning
Disability”?
• 1960s: “minimal brain dysfunction”
• 1963: Association for Children with
Learning Disabilities
• 1969: federal legislation
• 1975: US Public Law 94-142,
Education for all Handicapped
Children “least restrictive
environment”; 40% federal funding
commitment
IDEA, 2004
• Individuals with Disabilities
Education Act (PL 108-446)
• Part A General Provisions
• Part B (3-21 years); free and
appropriate public education
• Part C (0-3 years); early intervention
services
• Part D National Activities
IDEA, 2004
• More than 6 million children receive
special education under IDEA (2009)
• 44% of these are for “learning
disabilities”
• 11.5% (1991) to 13.5% (2005) in
U.S.
• Peaked at 10.6% in 1999 in
California and has since declined
slightly to 10.4% (2007)
Special Education
• Amount spent per non-disabled child in
public school $7,000/year
• Amount spent per child in special
education $23,000/year
• Federal mandate with no fiscal backing—
6-15%, not 40%
• Of $9.3 billion spent on special education
in California in 2007, very little comes
from federal government; shift of burden
from state to local districts
IEP:
Individualized Education Plan
• Cornerstone of Special Education Law
• Developed by special educator/school
psychologist, child’s teacher, and child’s parent(s)
• Includes following 3 components:
– Child’s eligibility for special education
– Programs to be provided
– Criteria to evaluate progress
IEP:
Individualized Education Plan
• California timeline (law)
• School has 15 days to provide parents with plan
for assessments after written request received
• Parents have 15 days to approve assessment
plan
• School has 50 days to complete assessment and
hold IEP meeting
Types of Special Education
• Regular classroom
– Special education
teacher consults
– Team teaching,
teacher’s aide
• Resource room
– Remedial
instruction
– Tutorial instruction
– Special skills
• Pull-out class
– Join regular ed
students for lunch
and P.E.
• Special schools
– Day programs
– Residential
programs
Case
Lisbeth is a 16-year-old in high school
whose mother brings her to the clinic.
The mother reports that Lisbeth won’t do
her homework, that she spends all day on
the phone with her friends, and this year
she went from being an A’s and B’s
student to a D student. Lisbeth appears
angry and won’t answer your questions in
the clinic, even when you ask her mother
to leave the room.
Mental Health in Schools
• AB 3632 (1984): entitlement to mental
health service for school children with
serious emotional disturbances
• Specifies that therapy treatment services
be provided by the Department of Mental
Health in the public schools and be
exempt from financial eligibility standards
and family repayment requirements
Case
Justin is a 15-year-old who has ADHD
and severe emotional disturbance.
He has been in special education
since 3rd grade. The schools want to
send him away to a residential
program and Mom wants him to live
at home and attend a day treatment
program. She is appealing to you as
her pediatrician to help them.
Case
• Annie is a 10-year old girl in fifth
grade with type 1 diabetes. She is
an average student but struggles
with math. Her mom reports that
she goes to the resource room twice
a week for special math tutoring.
You astutely ask about Annie’s IEP,
and Mom has no idea what you’re
talking about. What’s going on?
Section 504
of the Rehabilitation Act
• Accommodations must be made for
individuals with disabilities in
institutions that receive federal
funds—civil rights violation
• Parents have no legal rights to
assessments, contest treatment
plan, or fair hearing
Conclusions
• School Function at Simms = social justice
• K-12 is not on a curve; our patients should be expected to
make A’s and B’s
• Being bilingual is not a reason to repeat a grade
• Academic success is a prerequisite for breaking the cycle of
poverty
• “The metric of success for pediatricians should be the high
school graduation rate of their patients”—Bob Brook