After the screen…
Katherine Hobbs Knutson MD MPH
Elizabeth Rihani, Manager, Child Find-Early Stages
DC Learning Collaborative
February 6, 2015
Disclosures
• No relevant disclosures.
• No relevant conflicts of interest.
• There will be no discussion of off-label use of
medications.
Learning Objectives
• Identify screening tools and potential results.
• Based on screening results, develop methods
for further evaluation.
• Identify when specialty referral may be
indicated and community resources for
referral.
• Introduce treatment methods for behavioral
health problems within primary care.
Screening tools
• Edinburgh postnatal depression scale (EPDS)
• Ages & Stages questionnaire – social
emotional (ASQ-SE)
• Strengths & Difficulties questionnaire (SDQ)
– Add CRAFFT & suicide screen for teens
• Patient Health Questionnaire-9 (PHQ-9)
Setting the stage for screening

Before providing the screen, prepare parents and youth in advance.



It is natural for families to feel apprehensive around MH discussions


Pamphlets or videos in the waiting area and exam rooms to expose parents to the
concept of behavioral-health screening
Clarify what screening means: not a diagnosis
Apprehension eases when the screening process is explained
How medical staff approaches topic of MH with a family can impact family’s
understanding of and participation in interventions

Use the idea of a partnership, conveying respect for the parents as an expert on the
child and continually seeking their perspective on the child and the situation
Discussion of a negative screen

If the results of the screen are reassuring (“negative”)

Acknowledge as such to the parent/guardian and youth



“Things seem to be going well-- that’s terrific.”
Ask if any questions came up while the form was being completed

This can help to build the provider-patient relationship

More likely to come to you if mental health issues emerge in the future
Don’t forget to document and bill for screening

CPT code 96110 (TS modifier for at risk screens)
Negative screen
• Provide anticipatory guidance for social and
emotional development for the upcoming
year.
• Explain that screening will continue annually.
• Encourage families to contact providers with
social, emotional or behavioral concerns.
Borderline or positive results
Borderline or positive results
• Discuss concerning sections with the family (at
the current or a subsequent visit)
– Clarify that the screen does not make a diagnosis
Borderline or positive results
• Discuss concerning sections with the family (at
the current or a subsequent visit)
– Clarify that the screen does not make a diagnosis
• Goal: Make decisions about management
– Follow and reevaluate
– Manage within primary care
– Refer for specialty care
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Borderline or positive results
• Nature of the problem:
Borderline or positive results
• Nature of the problem:
– Developmental concerns (including autism):
• Motor
• Verbal
• Cognitive/adaptive
Borderline or positive results
• Nature of the problem:
– Developmental concerns (including autism):
• Motor
• Verbal
• Cognitive/adaptive
– Behavioral concerns: with an ear toward…
•
•
•
•
•
ADHD
Anxiety
Depression
Substance abuse
Oppositional behavior
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Borderline or positive results
• Impact of the problem on function
– Consider the impact supplement for the SDQ
SDQ Impact
Supplement
SDQinfo.org
~ Severity
~ History
1
~ Impairment
1 = Borderline
2+ = Clinical
2
Borderline or positive results
• Impact of the problem on function
– Home
– School
– Peers/community
Borderline or positive results
• Impact of the problem on function
– Home
– School
– Peers/community
Borderline or positive results
• Impact of the problem on function
– Home:
• Do caregivers feel capable of limit setting and managing
behavior (special case: foster care)?
• Does the family feel safe?
• Does the child/teen elope?
• Is there significant distress at home due to the child’s
behavior?
• Does the child’s behavior impact family functioning
(e.g., ability to go to the store, remain employed)
Borderline or positive results
• Impact of the problem on function
– Home
– School
– Peers/community
Borderline or positive results
• Impact of the problem on function
– School:
• Attendance.
• Grades declining.
• Suspensions/disciplinary measures.
Borderline or positive results
• Impact of the problem on function
– Home
– School
– Peers/community
Borderline or positive results
• Impact of the problem on function
– Peers/community:
• Quality of friendships.
• Social engagement/withdrawal (teens: texting, social
media).
• Legal issues.
Borderline or positive results
• Impact of the problem on function
– Home
– School
– Peers/community
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Borderline or positive results
• Safety issues
– Substance abuse
– Suicide
– Psychosis
Borderline or positive results
• Safety issues
– Substance abuse
• “Do you or your friends use drugs or alcohol?”
• If yes, then clarify types of drugs, amount & frequency
of use.
Borderline or positive results
• Safety issues
– Suicide
• “Do you ever have thoughts about hurting yourself or
sometimes wish you weren’t alive?”
• If yes, then clarify
– Any recent suicide attempt.
– Any plan or intent for suicide attempt currently or in the
recent past.
Borderline or positive results
• Safety issues
– Psychosis
• “Do you ever hear voices that others don’t hear?”
• If yes, then clarify if the voice(s) instruct the patient to
do things – with particular attention to instructions to
do anything dangerous.
Borderline or positive results
• Safety issues
– Substance abuse
– Suicide
– Psychosis
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Borderline or positive results
• Gather information about the following:
– Nature of the problem
• Developmental concerns
• Behavioral concerns
– Impact of the problem on function
• Home: limit setting, dangerous/safety concerns, eloping, family
distress
• School: grades, attendance
• Peers: quality of friendships, social engagement
– Safety issues
• Substance abuse
• Suicide
• Psychosis
Triage decision following a borderline
or positive screen
Triage decision following a borderline
or positive screen
• Developmental concerns (including autism):
– Motor
– Verbal
– Cognitive/adaptive
District of Columbia Public Schools
- Early Stages
Making Referrals
For children who are DC residents or who attend a DC child development center or private school
Strong Start
Early Stages
Age Range:
Birth to 2 years 10 ½ months
2 years 8 months to 5 years 10
months
Reason:
• Developmental delay
• Diagnosed condition or risk
factor associated with
developmental delay
• Parental concern
• Same as Strong Start
• Concerns over school
readiness and socialemotional issues
Examples:
Very low birth weight, genetic
condition, prematurity, hearing or
vision impairments, birth defects,
delayed speech, autism spectrum
disorders
Most common: speech delay,
developmental delay, as well as
physical and fine motor
concerns.
District of Columbia Public Schools
- Early Stages
Areas of Evaluation
Education
Speech and
Language
• A little bit of everything
• Fluency
• Articulation
• Comprehension
Occupational
Therapy
• Fine Motor Development
• Sensory Processing
Physical Therapy
• Gross Motor Development
Psychological
• Autism Concerns
• Behavior
• Adaptive and Social Skills
• Cognitive
Strong Start T: (202) 727-3665 I www.strongstartdc.com I Early Stages I T 202.698.8037 I www.earlystagesdc.org
District of Columbia Public Schools
- Early Stages
Where to Refer
Birth – 2 years, 8 months
Phone 202-727-3665
Email
[email protected]
Web www.strongstartdc.com

2 years, 8 months - 5 years, 10 months
Phone 202-698-8037
Email
[email protected]
Web www.earlystagesdc.org
District of Columbia Public Schools
- Early Stages
Determining Eligibility
Answer the
following questions:
Does the student have an
IDEA-defined disability?
If YES (to both): Student is
eligible for special
education and related
services; an IEP must be
developed.
AND
If NO: Determine if the
Does the disability have
an impact on the child’s
education?
student is eligible for
accommodations under
Section 504 and/or refer for
school-based support.
District of Columbia Public Schools
- Early Stages
Disabilities Under IDEA
Autism
Deaf-Blindness
Deafness
Developmental
Delay
Emotional
Disturbance
Hearing Impairment
Intellectual
Disability
Multiple Disabilities
Orthopedic
Impairment
Other Health
Impairment
Specific Learning
Disability
Speech or Language
Impairment
Traumatic Brain
Injury
Visual Impairment
(inc. Blindness)
District of Columbia Public Schools
- Early Stages
IEP Services
Special education is specially designed instruction that ensures the child’s access to the general
curriculum. Related services, if determined necessary, may include:
Specialized Instruction
Speech/Language Therapy
Physical Therapy
Occupational Therapy
Psychological Services
Audiology Services
Interpreting Services
Transportation
Vision Services
Extended School Year (ESY)
Assistive Technology Devices
Medical Services
School Health Services and School Nurse Services
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Triage decision
• Behavior concerns without impact on function
or safety concerns
– Consider providing guidance for caregivers &
reassess in 1 month
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Triage decision
• Behavior concerns with impact on function
Triage decision
• Behavior concerns with impact on function
– Consider treating within primary care (ADHD,
anxiety, depression, substance abuse)
Treatment within primary care
• ADHD
– Choose your favorite screening tool (Vanderbilt,
SNAP, etc.).
– If the child has ADHD symptoms at school and at
home that started prior to age 7yo with significant
impact on function, then consider treatment
(meds, therapy).
– Consider referral for IEP/504 at school.
– Follow up within 1 month of initiating treatment.
Treatment within primary care
• Anxiety
– Consider another screening tool such as SCARED.
– Treatment:
• Therapy.
• SSRI medication for severe impact of anxiety on
function and/or continued anxiety symptoms despite at
least 6 weeks of therapy.
• Consider referral for IEP/504 at school.
Treatment within primary care
• Depression
– Consider another screening tool such as PHQ-9.
– Treatment:
• Therapy.
• SSRI medication for severe impact of depression on
function and/or continued anxiety symptoms despite at
least 6 weeks of therapy.
• Consider referral for IEP/504 at school.
Treatment within primary care
• Initiation of SSRI medication
– Rule out history of mania.
• Decreased need for sleep + severe behavioral dysregulation,
rapid speech, grandiose thoughts, reckless behavior.
– Warn families about risk of suicidal ideation.
• Rare, incremental risk, call 911 for any concerns.
– Warn families about initial side effects including GI
upset and headache that will resolve.
– Follow up within 1-2 weeks of initiating SSRI
medication.
Treatment within primary care
• Substance abuse
– Gain an understanding of all drugs being used and
quantities.
– Motivational interviewing:
• Cutting down on drug use.
• Engaging in substance abuse treatment.
Triage decision
• Behavior concerns with impact on function
– Consider treating within primary care (ADHD,
anxiety, depression, substance abuse)
– Consider referring for mental health evaluation
• Resource guide
• DC MAP care coordinator
DCHEALTHCHECK.NET
DC Mental Health Resource Guide:
Triage decision
• Behavior concerns with impact on function
– Consider treating within primary care (ADHD,
anxiety, depression, substance abuse)
– Consider referring for mental health evaluation
• Resource guide
• DC MAP care coordinator
– Behavior problems impacting academic progress
and/or development: refer for Strong Start, Early
Stages, or IEP/504 depending on age
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Triage decision
• Behavior issues with safety concerns
– Consider calling CHAMPS (202.481.1450) or
sending to ED
• Active suicidal thoughts, recent suicide attempt,
psychosis, severe substance abuse
– Urgent referral for mental health if available
• Self-injurious behavior, passive suicidal thoughts, less
severe drug use
• Consider scheduling another visit in 2-3 days while
waiting for mental health evaluation
Triage decision following a borderline
or positive screen
Borderline/Positive
screen
Developmental
concerns
Refer for Strong
Start, Early Stages,
or IEP/504
depending on age
Behavior concerns
No functional
impairment or
safety concerns
Provide guidance &
follow in one
month
With functional
impairment
Treat in primary
care
Refer to specialty
care
With safety
concerns
Refer to ED
Refer for urgent
mental health
evaluation
Learning Objectives
• Identify screening tools and potential results.
• Based on screening results, develop methods
for further evaluation.
• Identify when specialty referral may be
indicated and community resources for
referral.
• Introduce treatment methods for behavioral
health problems within primary care.
Questions?
Katherine Hobbs Knutson, MD MPH
[email protected]