Transcript Integrating Mental Health in Pediatric Primary Care

Dianna Inman, DNP, APRN,CPNP-PC, PMHS
Assistant Professor
University of Kentucky

Financial
◦ I have no financial relationships to disclose
◦ Off Label use:
I will discuss off-label use of medications

After completion of this session, the participant
should be able to:
◦ Identify behavioral/mental health needs and substance
use of children and adolescents in KY.
◦ Screen, Diagnose and Treat common mental
health/behavioral problems that occur in primary care
◦ Discuss common pharmacological treatments for ADHD,
Depression and Anxiety
◦ Identify Changes in the DSM – V that apply to Pediatric
behavioral health
◦ Adopt one strategy to promote behavioral health in
practice





Limited mental health services- national
shortage of Child Psychiatrists and Psychiatric
Nurse Practitioners
Current rate of service utilization ~12,624
child and adolescent psychiatrists are needed
The # of available psychiatrists through 2020
is projected as 8,312 (AACAP, 2009)
Shortage of mental health services, especially
in rural areas
Only 20% of children and adolescents receive
MH services that need them

The term “behavioral health” refers to the
promotion of mental health, resilience, and
well-being; the prevention and treatment of
mental and substance use disorders; and the
support of those who are in recovery from
these conditions, along with their families
and communities.
◦ Adapted from WHO, SAMHSA

21% of children & adolescents in the U.S.
meet diagnostic criteria for a mental health
disorder.
◦ 11% of children and adolescents experience serious
mental disorders with functional impairment in
school, at home & with peers.
Only 50% receive services for mental health.
9 % of teenagers meet criteria for depression at any
time.
1 in 5 teens have depression during adolescence.
Suicide remains the 3rd leading cause of death ages
11-18.

Mental illness has its roots in adolescence:
◦ Half of mood disorders, anxiety, impulse-control &
substance use starts by age 14
PCP’s under identify children with mental health
problems, especially mood and anxiety related
symptoms
15 % of adolescents consider suicide
7 % make attempt
83% of adolescents who attempted suicide had been
seen recently by PCP and suicidal thoughts were not
identified


24% of pediatric primary care visits involve
behavioral, emotional or developmental
concerns.
70 % of adolescents see a primary care
provider (PCP) at least once a year.
Only 23 % of PCPs screen for mental health
disorders
Only 34% of youth report provider talked to them
about their emotional health
Missed opportunities, think immunizations
 Foy, Perrin, & AAP Task Force, 2010





Suicide
◦ 90% of children and adolescents who commit suicide have a mental disorder
Higher Health Care Utilization
◦ Youth experiencing emotional and behavioral problems seek more health care
◦ Higher health costs in their adult years than others their age
School Failure
◦ 50% of students 14 and older with mental illness drop out of high school; the
highest dropout rate of any disability group
Juvenile and criminal Justice Involvement
◦ Many youth with unidentified and untreated mental illness end up in jails and
prisons
◦ 65% of boys and 75% of girls in juvenile detention have mental illness
Long Term Disability
Mental Illness it the 2nd leading cause of disability and premature mortality
in the U.S.


Biological health risk factors in children
Stress
◦ Intrauterine stress
◦ Early social and emotional stress experiences
◦ Biological stress reactivity
 (i.e., psychological resilience, immunologic resistance)


Genetics
CSHCNS, obesity

Psychosocial risk factors
◦ Family and parental mental health-depression,
anxiety, substance use, ADHD
◦ Poverty
◦ Exposure to violence- abuse, domestic violence,
community violence
◦ Stressful life events
◦ Peer influences
◦ Sexual Identify
◦ Shyness vs. social phobia

“Integration of mental health into pediatric
primary care is essential if we are to treat our
children and teens in a holistic way. The
need is great and the time is now for
providers and practices to make changes so
our nation’s children can be treated
appropriately.”
◦ Susan Van Cleve, DNP, CPNP-PC -Past President





Mental health issues are common in children and teens and can portend
complex medical and mental disorders in adulthood
MH Disorders affect approximately one in four to five children and teens and
are beginning to surpass physical health problems
MH Disorders are treatable but fewer than 25% of children and teens with MH
disorders receive any treatment.
Why primary care: NAPNAP, PNCB-new certification PMHS, AAP
Primary care is usually the first and often the only contact that patients have with
health care professionals.

Primary care interventions can be sufficient, without need
for referral to mental health specialists.

Who says so:

Kentucky’s percentage of illicit drug use among
adolescents was lower than the national percentage
in 2012-2013. (National Data 9.2%, KY 7.0 %)
◦
15.0%
10.0%
5.0%
0.0%
10.1% 10.1% 9.8%
9.2%
8.4% 8.5% 7.9%
7.0%
Kentucky
United
States

Kentucky’s percentage of cigarette use
among adolescents was higher than the
national percentage in 2012-2013.
(National 6.1%, KY 9.5%)
15.0%
10.0%
5.0%
0.0%
11.0% 11.7% 11.6%
9.5%
8.7% 8.1%
7.2%
6.1%
Kentucky
United States

Kentucky’s percentage of binge alcohol use
among people aged 12 -20 was similar to the
national percentage in 2012-2013. (National
14.7 %, KY 14.5%).
◦ In Kentucky, about 82,000 people aged 12-20 (16%
of all people in this age group) per year in 20092013 reported binge alcohol use within the month
prior to being surveyed.

Past-Year Initiation of Substance Use Among
Adolescents Aged 12-17 in Kentucky, by
Substance of Abuse (2009-2013)
9.4%
10.0%
5.0%
0.0%
4.4%
5.0%
2.5%
Adolescents aged 12-17 in Kentucky and the United
States who perceived no great risk from smoking one or
more packs of cigarettes a day (2009-2013)
42.0%
40.0%
40.1%
38.3%
38.0% 36.6%
35.0%
36.2%
34.6% 34.3% 34.1%
36.0%
34.0%
Kentucky
32.0%
United States
30.0%
Adolescents aged 12-17 in Kentucky and the United
States who perceived no great risk from smoking
marijuana once a month (2009-2013)
80.0%
70.1% 71.4% 73.0% 74.7%
69.3%
65.5%
70.0% 60.5% 61.4%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Kentucky
United States

PCPs can have a positive effect on a child’s
mental health problem without knowing
precisely the diagnosis
◦ Traditional approach that diagnosis follows treatment
 Only offers partial help for most children with behavioral or
mental health problems seen in primary care-those with
significant problems dysfunction in the absence of a specific
diagnosis

PCCs can expand their knowledge beyond
treating ADHD and care for children with other
commonly occurring pediatric mental health
problems including anxiety, depression and
substance abuse.

PCPs can routinely screen for mental health
problems
◦ Recognize symptoms early
◦ Educate children and families about selfmanagement strategies,
◦ Offer first-line treatment to prevent more severe
problems and impairment
◦ Children with chronic medical conditions and
comorbid mental health needs – improve physical
health and decrease utilization of emergency
department and hospital services.
Skills
Knowledge
Attitude





Local, regional, national conferences &
continuing education programs
AAP Developmental/Behavioral Pediatric PREP
courses
AACAP Annual Conference
REACH (Resource Advancing Children’s
Health) Institute-programs for PCPs on
developing MH skills
Psychopharmacology training



Every visit is an opportunity to screen for
mental health disorders
Just Like Immunizations-Do Not Miss An
Opportunity to Intervene/Treat
Tools For Screening:
◦ General Screening Tools For Mental Health
Assessment:
 PSC- Pediatric Symptom Checklist
 HEADSS
 RAAPS






HEADDS
PSC- 17
RAAPS
PHQ-A
SCARED
CRAFFT



Short form is 17 items and takes 5 minutes for the parent or
patient to complete
A PSC-17 score of 15 or higher suggests the presence of
significant behavioral or emotional problems.
To determine what kinds of mental health problems are
present, determine the 3 factor scores on the PSC:

The majority of health problems among
adolescents are due to risky behaviors rather
than biological dysfunction. Did you know that
the primary causes of premature death and injury
are preventable in nearly 75% of the adolescent
population? Almost 3/4 of adolescent mortality is
a result of motor vehicle crashes, homicide,
suicide and unintentional injuries. These causes
are rarely screened for or directly counseled
during heath care visits - even with national
recommendations in place.
ORGANIZATION
ADOLESCENT HEALTH RISK
SCREENING RECOMMENDATIONS
American Medical Association
(AMA)
Annual comprehensive screening
for risky behaviors
American Academy of Pediatrics
(AAP)
Annual screening
psychosocial/behavioral
assessment & drug/alcohol use
assessment
US Preventive Service Task Force:
AHRQ
Screening for depression and
tobacco use/prevention
American Academy of Family
Physicians (AAFP)
Screening for sexual activity,
depression, tobacco use
American College of Preventive
Medicine
Annual comprehensive screening
for risky behaviors - all visit types


The Rapid Assessment for Adolescent
Preventive Services© RAAPS is a validated risk
assessment & counseling system designed for
9-24 year olds.
Provides Assessment of High Risk Behaviors
and Risk Reduction Counseling
◦ https://www.raaps.org/videos.php
The youth
and clinician
will view the
side bar with
the
information,
risks and risk
levels(if
applicable),
and a goal
progress bar.
RAAPS Questions Example: For a full list of questions, please
contact [email protected]
Depression
Past-year major depressive episodes (MDE) among
adolescents aged 12-17 in Kentucky and the United
States (2009-2013)
12.0%
10.0%
8.7% 9.9%
8.4% 8.9% 9.5%
9.1%
8.1% 8.1%
8.0%
6.0%
4.0%
Kentucky
2.0%
United States
0.0%
Past-year depression treatment
among adolescents aged 12-17
with major depressive episdoe
(MDE) in Kentucky (2009-2013)
Received
44.1%
55.9%
Treatment for
Depression
Past-year serious mental illness among adolescents aged
12-17 in Kentucky and the United States (2009-2013)
6.0%
5.0%
4.0%
4.0%5.0%
4.1% 4.6% 4.7%
4.1%
3.9% 3.9%
3.0%
2.0%
Kentucky
1.0%
United States
0.0%
Past-year thoughts of suicide among adolescents aged
12-17 in Kentucky and the United States (2009-2013)
4.2%
4.1%
4.1%
4.0%
4.1%
4.0%
4.0%
3.9%
3.8%
3.7%
3.6%
3.8%
3.8%
3.8%
3.9%
Kentucky
United States
Past-year mental health
treatment/counseling among
adolescents aged 12-17 in
Kentucky and the United States…
Received
Treatment
PHQ-9 Teen (Patient Health
Questionnaire)- free and available to
the public
 Center for Epidemiological Studies
Depression Scale for Children (CESDC) - free and available to the public
domain at www.brightfutures.org
 Beck Depression or Beck Youth
Inventory


The USPSTF recommends screening all teens
ages 12-18 years of age for Major Depressive
Disorder when systems are in place to ensure
accurate diagnosis, psychotherapy (CBT or IP)
and follow up. Screening raises a red flag
which then requires a clinical interview and
further evaluation by the healthcare provider


Bipolar and Related Disorders – separated
from depressive disorders in the DSM 5
Disruptive Mood Dysregulation Disorder
◦ For the diagnosis of Bipolar I Disorder, it is
necessary to meet the criteria for a manic episode.
The manic episode may have been preceded by and
may be followed by hypomanic or major depressive
episodes

There is a 15x higher rate of suicide in
bipolar disorder






Depressive disorders are appearing at a younger age of onset
20 % of teens experience clinical depression before adulthood.
10 - 15 % of teens have some symptoms of depression at any
one time.
5 % of teens have major depression at any one time
8 % of teens have depression for at least a year
Suicide is the 3rd leading cause of death among teens and
young adults

Major Depression- is the medical term for depression that includes five of the symptoms listed
below. A person may have mild, moderate or severe major depression.
 Sadness most of the day, particularly in the morning
 Markedly diminished pleasure or loss of interest in almost all activities nearly every day
 Significant weight loss or weight gain
 Insomnia or excessive sleep
 Agitated movements or very slow movement
 Fatigue or loss of energy
 Feelings of worthlessness or guilt
 Impaired concentration and indecisiveness
 Recurring thoughts of death or suicide
The symptoms must be present during the same time period and must persist for the same
two weeks and represent a change from previous functioning. One of the symptoms must be
either depressed mood or loss of interest.

Dysthymia – is a low grade depression that persists for
a long period of time. Dysthymia is a usually
diagnosed when a person has had depressive
symptoms for at least two consecutive years (causing
distress or impairment). The most common
symptoms of dysthymia include an absence of
pleasure or interest in activities, low self-esteem and
low energy.









Mood: irritable or depressed plus
Sleep: increased or insomnia
Interest: markedly decreased in activities
Guilt: feeling worthless, inappropriate guilt
Energy: fatigue or loss of energy
Concentration: hard to think/concentrate
Appetite: significant wt loss / gain (~ 5% change)
Psychomotor activity: physically slowed or agitated
Suicide: thoughts, attempts, death thoughts

Mild: 5-6 sx of mild severity (including mood) + function
mildly impaired or normal but w/ substantial and unusual
effort

Moderate in between mild and severe

Severe: most sx present and severe +
Function is disabled, clearly observable
Or
Psychotic features are present


Physical illness: targeted review of systems, labs
Substance / alcohol use, 20 – 30%
◦ usually follows depression onset by ~ 5 years



Other mood and psychiatric disorders:
Dysthymia (Persistent Depressive Disorder), Bipolar
Disorder (Disruptive Mood Dsyregulation), Anxiety,
ADD, ASD, ODD or Conduct Disorders, Psychotic
disorders (hallucinations, paranoia)
Abuse: physical / emotional / sexual
 Medical
History
 School History
 Social History
 Family History



Mood- Have you been feeling sad, down, blue or
grouchy most of the day, more day than not? Do
you find yourself crying a lot? Have you been
getting into arguments more than usual?
Anhedonia: Are you able to enjoy things you
used to enjoy? Do you feel bored or tired a lot of
the time?
Neurovegetative signs: Do you have trouble
falling asleep or staying asleep? Do you have
trouble concentrating in school? How is your
appetite-are you eating more or less than usual?




Somatic symptoms-Do you have a lot of
headaches or stomachaches?
Negative self-concept? On a scale of 0 to 10
with 0 meaning not good at all to 10 meaning
very good, how do you feel about yourself?
Guilt: Do you feel badly or guilty about
things you have done?
Relationships with friends: Do you have
friends? Are you liked by other kids?



Suicidal ideations: Do you ever wish you were
dead; Do you think about death; Do you have
a plan to hurt yourself; Have you every hurt
yourself?
Current health and medications: illnesses,
medications can cause mood disorders
Alcohol and drug use: How much alcohol do
you drink? What drugs are you taking? How
often?





Degree of hopelessness is the #1 predictor;
not future oriented
Method available to patient
Family history of suicide or recent suicide in
school or community
Giving away treasured items
Prior history of self-harming behavior or
impulsivity
A
complete physical exam should
be performed
 Laboratory tests: TSH: FT4, CBC
with differential, urine toxicology
screen, pregnancy test in sexually
active teens




Form an alliance w/ the teen and affirm hope
Educate, counsel patient and family about depression,
management options, limits of confidentiality
Establish a safety plan: restrict access to lethal means,
engage 3rd party to monitor for deterioration/risk,
develop emergency communication plan to use if
needed
Develop a specific tx plan and goals regarding function
in home, school and peer relationships





Share resources for support: phone #s, websites,
handouts
Refer patient and family to mental health providers
Arrange follow up visit within one week
Have family sign release of information form to allow
communication w/ school staff, outside providers.
Obtain information from and communicate w/ school
staff, health care providers. Keep them informed about
your tx plans and concerns.
Ginsburg K: Building Resilience in Children and Teens: Giving Your
Child Roots and Wings






Active support through PCP
See pt weekly or biweekly x 6 – 8 wks:
Non directive support (support is equally effective as formal
psychotherapy for mild depression)
Monitor depressive symptoms and function (school, home,
peer)
If sx persist > 6 – 8 wks, offer psychotherapy and / or
antidepressants
Refer patient and family to mental health care providers when
appropriate
“support is equally effective as formal psychotherapy for
mild depression”


Teen’s definition: Resilience means “bouncing back from
problems and stuff with more power and more smarts."
Nurturing resiliency:
◦ Demonstrate to pt that s/he has strengths (name them, show pt how s/he
is using them, suggest how pt can use them in the future)
◦ Be patient, keep communicating these to pt over serial visits
◦ Adapted from Nan Henderson, The Resiliency Training Program


Video Clip
http://www.values.com/inspirational-storiestv-spots/99-The-Greatest
TADS (Treatment for Adolescents with Depression Study): 439 teens 13 - 17 y/o with
moderate to severe depression
1. Cognitive Beh Tx (CBT) + Fluoxetine
2. CBT alone
3. Fluoxetine alone
 Higher first response rate CBT+ Fluoxetine combined - Improved @ 12 wks: 71% Combo
v. 61% SSRI v. 44% Talk; @ 36 wks: similar outcomes for all groups
 Remission: faster for combo tx: by 36 wks: 55% for fluoxetine, 60% combo, 64% CBT
 Anti depressants can take 1 – 3 months to work
 Once stable continue med for 6 - 9 months

Treatment for Adolescents w/ Depression Study, Am J Psychiatry. 2009 ;166(10): 1141-1149.
https://trialweb.dcri.duke.edu/tads/manuals.html

Cognitive Behavioral Therapy (CBT) is effective and less costly than other talk tx, eg
Interpersonal Therapy

CBT Principles: thoughts cause feelings & behaviors, not external things (people,
situations, events).

Focus: Change the way you think and react in order to feel & act better even if
externalities don’t change.

Approaches: attend to thoughts and behaviors, practice to change them
(in contrast to Interpersonal Therapy, which focuses primarily on improving
relationships)

◦ Recommended by WHO
Consider starting antidepressant and recommend
psychotherapy
Or
Refer to Psychiatrist


See patient weekly or every other week x 6 – 8 wks:
Monitor depressive symptoms and function (school,
home, peer)



Next 6 months: Continue meds after sx
resolution; track adherence and side effects
After full remission: monitor monthly for 6
months
Up to 24 months: regular follow up in primary
care







If Partially Improved
If no med, consider adding
If on med, consider increase dose
If no psychotherapy, start
Consult with or refer to psychiatrist
Review safety plan
Provide further education



Establish safety plan
Establish schedule for close follow up and
communication
Review short & longer term side effects of
meds and warning signs requiring immediate
attention (including mania, suicidal ideation)
Who says so?
AAP, AACAP, PC-Glad - II
Why?
Many teens and / or parents are reluctant to seek help from mental health
providers.
Widespread problems with limited or delayed access to psychiatrists for teens
Which Patients?
* uncomplicated mild depression that persists
* moderate depression
How?
Guidelines are clear about how to start meds, follow patients and when to seek
specialty referral




Fluoxetine (Prozac): approved by FDA for use
in treating depression in children ages 8 and
older
Celexa: Least activating
Luvox: Most activating
The trial of an SSRI should be for at least 812 weeks; if no improvement, consider crosstapering and substituting another SSRI
Generic Name
Trade Name
Dose
Cost
**Citalopram
Celexa
SD=5mg
DD= 10-20 mg
$$$
**Sertraline
Zoloft
SD=12.5 -25
mg
DD:50 – 100 mg
$$$
*Fluoxetine
Prozac
SD=5 mg
DD=10 -20 mg
$$
*Escitalopram
Lexapro
SD=5mg
DD=10 mg
$$$
• *FDA approval for Depression
• **FDA approval for OCD





Excitation/agitation
Nausea/vomiting
Diarrhea
Dizziness
Chills
◦ Always educate regarding risks of serotonin
syndrome (e.g. agitation, insomina)



Weekly x 4 week
Every 2 weeks x 2
weeks
Monthly
◦ Dosage change, see
pt in 2 weeks
◦ Sooner for any
concerns




Anyone who wants such a referral
Moderate Depression w/ Complicating Factors
(eg substance abuse, ADHD, other psych illnesses)
Severe Depression
Suicidal patient


COPE
CBT



First developed as a 15 session intervention:
The COPE Healthy Lifestyles TEEN (Thinking,
Emotions, Exercise and Nutrition) Program
Young Adult Manual, Teen Manual & Child
Manual – colorful and developmentally
appropriate. Portable, can be delivered in 20
-30 minutes
Has been used effectively in clinics, office
practices, and schools in individual, group
and classroom formats


CBT originated from cognitive theories that
were developed by Beck and Ellis, and
behavioral theories developed by Skinner and
Lewinsohn
Active components of CBT include reducing
negative thoughts (cognitive restructuring),
increasing pleasurable activities (behavioral
activation), and improving assertiveness and
problem-solving skills (homework
assignments)
Thinking
Feeling
Behaving
The thinking/feeling/behaving triangle


Lewinsohn & Clarke stressed that the lack of
positive reinforcement from pleasurable
activities leads to negative thought patterns
Behavior theory suggests that individuals are
depressed/ anxious because of a lack of
positive reinforcements and a lack of skills to
elicit positive reinforcement from others or to
terminate negative reactions from others







1. Thinking, Feeling, and Behaving: What is the
connection?
2. Positive Thinking and Forming Healthy
Thinking Habits
3. Coping with Stress
4. Problem Solving & Setting Goals.
5. Dealing with your Emotions in Healthy Ways
through Positive Thinking and Effective
Communication
6. Coping with Stressful Situations
7. Pulling it all together for a Healthy You



A cognitive behavioral skills building
evidence-based program for depressed and
anxious children, teens and young adults
Can be delivered in individual brief sessions
(20 – 30 minutes) or in group sessions (45 –
50 minutes)
The 7 sessions focus on CBT concepts and
skills
Individuals learn the ABCs in CBT and COPE
Activator or Antecedent event: A friend made
fun of me
 Belief: I’m an idiot
 Consequence of the belief: Feelings of
worthlessness and depression; difficulty
functioning


1.
2.
3.
A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development as characterized by:
Inattention: 6 ( or more) symptoms: For older
adolescents age 17 or older, at least 5
symptoms are required
Hyperactivity and impulsivity: 6 ( or more)
symptoms: For older adolescents age 17 or
older, at least 5 symptoms are required
Several symptoms were present prior to age 12
years



Medications
Parent-mediated behavioral modification
School-based interventions
◦ Behavioral
◦ Academic
◦ Meta-cognitive skills: organization, time
management

First line
◦ Stimulants
Previous second line
Atomotexine
Bupropion
TCAs
New second line
Alpha agonists
Additional meds:
Anxiety/depression: SSRIs
Aggression: Atypical
antipsychotics (off-label)





Peers: reduces aggression improves interaction
Home: improve parent-child interactions & on-task
behaviors
School improves sustained attention, organization &
speed of motor responses, & motor inhibitory control
Common adverse events in 4 %: insomnia, anorexia,
SA/HA, dizziness
Less frequent side effects: rebound, tics, compulsive
picking, growth delays, cardiovascular, psychiatric
Name
Amount (mg)
Hours
Adderall
(amphetamine salts)
7.5, 10, 12.5, 15, 20,
30
4-6
Dextroamphetamines
5,10
4-6
Methylphenidate
(Ritalin)
5,10, 20
3-4
Methylin
5,10,20 (chewable
tabs: 2.5,5,10; oral
solution: 5/
10mg/5ml
3-4
Focalin
(dexmethylphenidate)
2.5, 5, 10
4-5
Name
Amount (mg)
Hours
Release
Adderall XR
5,10,15,20,25,3
0
10-12
50% IR
Concerta
18,27, 36, 54
8-12
22 % IR
Focalin XR
5, 10, 20
8-10
Steady
Metadate CD
10,20,30
4-8
Steady
Metadate ER
10, 20
4-8
30% IR
Methylin ER
10
6-8
Steady
Ritalin LA
10, 20, 40
4-8
50% IR
Ritalin SR
20
4-8
Steady
Vyvanse
(lysdexamfetamin
30, 50, 70
12
Steady
e)

New versions of alpha agonists used alone or
as adjuvant treatment
Medication
Dosage
Duration
Side Effects
Kapvay
(Clonidine)
0.1 mg, 0.2 mg
10 -12+
Sleepiness,
irritability, low
BP, dizziness,
dry mouth,
constipation,
sex drive,
rebound HTN,
cardiac?
Intuniv
(Guanfacine)
1,2,3, 4 mg
(noncrushable)
10 – 12 +
Same although
sleepiness less
than clonidine

Rates detected by the FDA were NOT above
background rates in the general population
◦ Annual incidence of sudden death 0.6-6 per
100,000
◦ Data that medication can cause a statistically but
not clinically significant change in HR & BP
◦ At this time, the data suggest that use of these
medications is NOT associated with sudden death
◦ A good model for screening is the high
school/college athlete questions



SBIRT
CRAFFT
Resources: SBIRT:
http://www.nursing.pitt.edu/continuingeducation/sbirt-teaching-resources







http://www.glad-pc.org/
http://www.nichq.org/adhd.html
http://www.nachc.org/client/TeenScreen%20Screen
ing%20Questionnaire%20Overview%202%2017%201
1.pdf
http://www.tn.gov/mental/policy/best_pract/Page
s%20from%20CY_BPGs_445-453.pdf
http://www.parentsmedguide.org/
http://www.aacap.org/
http://www.sdbp.org/








Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care
Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF.
Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at:
http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf
Heath B, Vise Romero P, and Reynolds K. A review and Proposed Standard Framework for Levels of
Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March
2013.
Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health,
American Academy of Pediatrics (AAP), (2009). Policy statement-the future of pediatrics: Mental health
competencies for pediatric primary care. Pediatrics: 124 (1), 410-417.
Committee on Health Care Access and Economics Task Force on Mental Health, American Academy of
Child and Adolescent Psychiatry (AACAP). (2009). Improving mental health services in primary care:
Reducing administrative and financial barriers to access and collaboration. Pediatrics 123 (4), 1248-1251
The Reach Institute. Glad Tool Kit. http://glad-pc.org/
Foy, J.M: American Academy of Pediatrics Task-Force on Mental Health. Enhancing pediatric mental
healthcare: Algorithm for primary care. Pediatrics 2010; 125 (3 suppl) S109-125.
Substance Abuse and Mental Health Services Administration. (2014). Mental and Substance Use
Disorders, Rockville, MD: Substance Abuse and Mental Health Services Administration.
Merikangas K.R., He J., Burstein M., et al. (2010). Lifetime Prevalence of Mental Disorders in U.S.
Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the
American Academy of Child & Adolescent Psychiatry. 49(10):980-989




Collins C., Hewson D.L., Munger R., Wade T. (2010). Evolving Modes of Behavioral Health Integration in
Primary Care. Milbank Memorial Fund.
American Academy of Pediatrics. Attention Deficit Hyperactivity Disorder Toolkit Elk Grove Village, IL:
American Academy of Pediatrics; 2011
Cooper. W. et al (2011) AHRQ : Effective Health care Program Research Reports. Attention Deficit
Hyperactivity Disorder medications and Risk of Serious Cardiovascular Disease in Children and Youth.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC.