Transcript Pediatrics - Grand Strand Advanced Practice Nurse Association

Adolescent Screening
Stacey Cobb, MD
Developmental-Behavioral Pediatrics
Assistant Professor of Pediatrics
University of South Carolina School of Medicine
Disclosures
• No actual or potential conflicts of interest
in relation to this program or presentation.
• No discussion of off-label
pharmacotherapy or devices.
Objectives
• Discuss the role of the Primary Care Provider
in adolescent screening
• Review the administration and interpretation
of the most widely used screening tools
• Develop action steps for positive screen
results
• Discuss barriers in various practice settings
Prevalence
• 11-20% of U.S. children at any given time
– Behavioral or emotional disorder
• 37-39% diagnosed with a behavioral or
emotional disorder by 16 years of age
– Disruptive behavior
– Anxiety
– Mood disorders
Leading Causes of Limitation due to
Chronic Conditions in US Children
1.
2.
3.
4.
Speech problems
Learning disability
ADHD
Other emotional, mental and behavioral
problems
5. Other developmental problems
6. Asthma or breathing problems
Current State of Care
• Clinicians in more that 200 practices surveyed
• 50.2% of providers never used standardized
measures to assess mental health
• Fewer than 7% of providers used standardized
measures more than 50% of the time
Bright Futures Recommendations
• Structured early developmental screening
• Annual screening starting at 11 years old
– Alcohol & Drug Use/Abuse
– Depression
• Fulfills EPSDT requirement for routine
psychosocial screening
Substance Abuse
• Leading cause of morbidity and mortality in
adolescents and young adults
• Risk-taking behaviors and injuries related to
substance use is common
• Adolescents with increased vulnerability to
addiction due to the developing brain
• Although common, use should not be
condoned or trivialized
Alcohol & Substance Abuse
• CRAFFT
– Use up to age of 21
– Interview or self-report questionnaire
• Without a parent or guardian present
– 4-9 questions depending on answers
– Score of 2 or higher identifies a problem
• Sensitivity of 76%, specificity of 94%
Alcohol & Substance Abuse
• CAGE-AID
– 16 years old and up
– Interview or self-report questionnaire
– 4 questions
– Score of 1 or higher is a positive screen
• Sensitivity of 79%, specificity of 77%
Action Plan for Substance Abuse
Screening
• Brief positive feedback for smart decisions
• Brief advice for substance users
– Clear advice to stop and educational counseling
• Motivational interviewing for problem users
– Behavior change or referral to treatment
• Local mental & behavioral health services
• Adolescent substance abuse services
Depression
• 2.6 million adolescents (12-17 years old) with
1+ major depressive episode in the past year
– 10.7% of the US population in that age range
• Increased risk of death by suicide
• Long-term associations
– Early pregnancy, decreased school performance,
impaired work, social & family functioning
Depression Screening Tools
• Center of Epidemiologic Studies Depression
Scale - Revised
– Updated for DSM-5
– Description
• 20 questions
• Scored on a Likert scale
• 16 or higher is considered depressed
– Acceptable psychometric properties
• Differences between genders and cutoff values
Depression Screening Tools
• Other tools with less evidence for use
– 2 Question Screen
– Mood & Feelings Questionnaire
– Strengths & Difficulties Questionnaire
Anxiety
• Lifetime prevalence in children & teens is
between 8-27%
• 29% lifetime prevalence with the majority
having onset in childhood or teen years
• Only 40% seek treatment within 1 year
• Early onset (<13 yo) more likely to be chronic
Anxiety Screening Tools
• SCARED – Screen for Child Anxiety Related
Disorders
– Parent and self report
• 8-11 year olds may need explanation
– 41 questions
– Subscales
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Generalized anxiety disorder
Separation anxiety
Social anxiety disorder
Panic disorder
School avoidance
Anxiety Screening Tools
• Spence Children’s Anxiety Scale
– Parent & self report
• Starting at age 8
– 45 questions
– Subscales
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Panic
Social phobia
Separation anxiety
Generalized anxiety
Obsessions/compulsions
Fear of physical injury
Broad Social Emotional Screens
• Beck Youth Inventories of Emotional and Social
Impairment
– Well-studied across demographic groups
– Self-report for 7-18 year olds
– Depression, anxiety, anger, disruptive behavior, and
self-concept
– 100 questions (20 for each domain)
• Pricing
– $10 for complete inventory
– $2.25 for individual inventories
Broad Social Emotional Screens
• Pediatric Symptom Checklist (17 or 35)
– Full and abbreviated forms for parents
• Full version with subscales
– Attentional, internalizing and externalizing problems
– Youth self-report >10 years old
– Functional impairment items
– Different cutoff values for various forms and ages
– Pictorial version available
– Sensitivity 80-95%, specificity 68-100% (35)
Broad Social Emotional Screens
• Strengths & Difficulties Questionnaire
– Youth self-report from 11-17 yo
– Parent report for ages 4 through 17
– 25 questions with impact supplement
• 5 subscales
• Emotional, conduct, hyperactivity/inattention, peer
relationships, prosocial behavior
– >80 languages
– Sensitivity 63-94%, specificity 88-96%
ADHD
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4-12% prevalence worldwide
8-11% in the United States
Male predominance
Inattentive type can be particularly subtle
ADHD Screening
• Vanderbilt ADHD Diagnostic Rating Scales
– Most widely used
– Teachers are very familiar
– Based on DSM criteria
– Functional impairment scale
– Brief screen for ODD, conduct disorder, mood
symptoms
ADHD Screening
• Use of total score for trending response to
therapy
– Add individual scores from questions 1-18
– Total possible is 54
– More sensitive trending rather than symptom
scores alone
Action Plan
• Evidence-based therapies
– CBT for mood disorders
– Parent-Child Interaction Therapy for behavioral
disorders in younger kids
– Triple P
• Pharmacological therapy
– Primary care providers
– Mental/behavioral health providers
• Frequent follow up until stabilized
Psychosocial Screens
• 1 in 5 children were living in poverty in 2010
– High risk for behavioral and emotional problems
• Parental surveys
– WE-CARE
– Family Psychosocial Screen
– Survey of Well-Being in Young Children
– Adverse Child Experience Score
Action Plan for Psychosocial Screens
• If you ask, they will tell…
• Social worker
• Need knowledge of community resources
– Food banks
– Shelters
– Safety plans
Barriers
• Only 23% of primary care clinicians use
standardized screening tools
• Time constraints (cited by 82% of PCP’s in 1
study)
• Competing clinical demands
• Cost burden
• Staff requirements
• Lack of consensus on tools
• Insufficient training and expertise
Implementation
• AAP Task Force on Mental Health
– Toolkit to aid implementation efforts
• Implementation steps
– Ready the practice
– Identify resources
– Establish office routines for screening
– Track referrals
– Seek payment
– Foster collaboration
Reimbursement
• 96110 – developmental testing, limited
– Multiple units can be billed
– Not covered by some private insurance providers
• Reimburses for review and interpretation of the
screening tool
Resources
• AAP Mental Health Resources
– www.aap.org/en-us/advocacy-and-policy/aaphealth-initiatives/Mental-Health/Pages/KeyResources.aspx
• Caring for Children with ADHD: A Resource
Toolkit for Clinicians
– National Initiative for Child Healthcare Quality
(www.nichq.org)
References
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Slomski A. Chronic mental health issues in children now loom larger than physical problems. JAMA.
2012;308(3):223-225.
Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright
Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project
Advisory Committee. Identifying infants and young children with developmental disorders in the
medical home: an algorithm for developmental surveillance and screening [published correction
appears in Pediatrics. 2006; 118(4): 1808-1809]. Pediatrics. 2006; 118(1): 405-420.
Brown RL. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a
primary care practice. Wisconsin Medical Journal. 1995:94(3) 135-140.
Dhalia S. A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Curr Drug
Abuse Rev. 2001:4(1):57-64.
Levy, SJL. Committee on Substance Abuse. Substance Use Screening, Brief Intervention, and Referral
to Treatment for Pediatricians. Pediatrics.2011;128:e1330–e1340.
Weitzman C. Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial
Aspects of Child and Family Health, Council on Early Childhood, Society of Developmental and
Behavioral Pediatrics. Promoting Optimal Development: Screening for Behavioral and Emotional
Problems. Pediatrics. 2015;135: 384-395.
Substance Abuse and Mental Health Services Administration, Results from the 2013 National
Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No.
(SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
Williams, SB. Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic
Evidence Review for the US Preventative Services Task Force. Pediatrics. 2009;123:e716-35.