Jason Jent, Ph.D. Assistant Professor of Clinical Pediatrics University of Miami Miller School of Medicine

Transcription

1 Screening and Understanding Behavioral Issues in Service Delivery Jason Jent, Ph.D. Assistant Professor of Clinical Pediatrics University of Miami Miller School of Medicine Eugene Hershorin, M.D. Professor of Clinical Pediatrics University of Miami Miller School of Medicine

2 Disclosures My name is Jason Jent. I will be speaking about screening and understanding behavioral issues in service delivery. I have no relevant financial interests or conflicts of interests. I am employed by the University of Miami. I don t have other relevant financial interests to disclose. I am the Communications Task Force Chair for Parent-Child Interaction Therapy International. I don t receive any compensation for that role.

3 Disclosures My name is Eugene Hershorin. I also will be speaking about screening and understanding behavioral issues in service delivery. I have no relevant financial interests or conflicts of interests. I am employed by the University of Miami. I don t have other relevant financial interests to disclose. I am a member of the American Academy of Pediatrics, Florida Chapter of the American Academy of Pediatrics, Dade County Medical Association, Florida Medical Association, Society for Developmental and Behavioral Pediatrics. I do not receive compensation for my roles related to these memberships

4 Objectives Identify strategies to screen for behavioral issues in service delivery settings.

5 How can children s behavior impact service delivery/teaching?

6 Behavior Problems Impact Service Delivery Low frustration tolerance for perceived difficult tasks Difficulties starting tasks due to distraction Refusal to engage in tasks Difficulties maintaining attention and focus on task Failure to complete tasks that help drive service/teaching delivery Avoidant behavior due to fear or difficulty of task Learning behavior of child Learning of others Completion of tasks Your ability to provide service/teaching in a defined setting Parents ability to practice learned skills between sessions/classes

7 Prevalence of Psychiatric Disorders Approximately 10% of children meet criteria for a serious emotional disturbance that has a drastic impact on a child s functioning 15-27% of school-age children meet criteria at some point in time for disruptive behavior disorders Many go unidentified Rates of identification lower without the use of standardized screening. Berger-Jenkins et al., 2012; Berger-Jenkins et al., 2012; Costello et al., 2005; Simonian, 2004; Simonina & Tarnowski, 2001; Sayal & Taylor, 2004; Williams et al., 2004

8 Common Co-morbidities in Children with Disabilities Intellectual Disability Co-morbidities: - ADHD - Mood Disorders - Anxiety Disorders - Autism Spectrum Disorders - Self-injurious behaviors Communication Disorders Co-morbidities: - ADHD - Disruptive behaviors - Poor social competence ASD Co-morbidities: - ADHD - Disruptive Behavior Disorders - Anxiety Disorders - Depression Developmental Delays Co-morbidities: - Disruptive behaviors Children w/ Feeding Problems Co-morbidities: - Disruptive behaviors Children w/ Hearing Problems Co-morbidities: - Disruptive behaviors (American Psychiatric Association, 2013; Baker et al., 2003; Barker et al., 2009; Berlin et al., 2011; Leyfer et al., 2006; McCabe, 2005)

9 Consequences of Untreated Disruptive Behavior Problems Conduct Disorder Depression Academic and learning difficulties Social and peer problems Juvenile Delinquency Child Maltreatment Substance Abuse Criminal Activity Poor Adherence to Medical Regimens Burke et al., 2005; Farmer et al., 2002; Frick et al., 1991; Mordre et al., 2011; Murray et al., 2010

10 How does one decide if a child s behaviors are within normal limits?

11 Screening for Behavior by Interview vs. Standard Tool Using just an interview, pediatric providers average approximately a 70% true negative rate Pediatric providers ability to correctly identify children with behavior problems not as great (54% true positive rate) Validated screening tools are likely to increase the rate of true and false positives Sheldrick et al, 2011

12 Why Screen? Clearly Typical Under Detected Clearly Atypical? Adapted from Macias, M. (2006) D-PIP Training Workshop

13 Why Screen? Clearly Typical Under Detected Clearly Atypical? Adapted from Macias, M. (2006) D-PIP Training Workshop

14 Screening Beyond (Above or Below) Cutoff Near Cutoff Not Near Cutoff Diagnostic Assessment Continue to Monitor Provide information, support Refer to other agencies Eligible for services Not Eligible for services

15 Barriers to Using Screening Tools: The History Lesson of Pediatricians A growing list of competing demands during each pediatric visit Length of time required to screen Increased screening will overburden already overwhelmed mental health service programs Perceived lack of expertise Outside of perceived role Cost of screening tools No payment for screening Belamarich et al., 2006; Berger-Jenkins et al., 2012

16 Why Screening Tools Matters Within Pediatric Practices Behavior problems are typically reported to the doctor first Identification of problems increase Parents are more willing to discuss problems with pediatricians due to the stigma of mental health Referrals increase for services increase Adherence to mental health referral increases (40% to 83%) when provided by a pediatrician Berger-Jenkins et al., 2012; Wissow et al., 2013

17 Why Screening in Other Settings Matter Better understanding of the child s relative strengths and needs Allows for tailoring interactions accordingly Identifies whether behavior warrants additional attention Early identification and intervention increases probability of optimal outcomes Hypothesis generation based on who completed measures- interview vs. screening results Context for parents to understand their child relative to other children

18 Screening in Your Setting When to screen Universal vs. selective screening What evaluation information is already available to me Costs of screening Expertise needed to screen and interpret results Comfort with providing feedback to families Linking families for assessment

19 The Ages & Stages Questionnaire: Socioemotional Second Edition Screens socioemotional development of children between 1 and 72 months Available in English and Spanish Screens 7 behavioral domains including: selfregulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people Externalizing and internalizing behaviors targeted Bridge communication between parents and professionals about child s behavior Squires et al., 2015

20

21

22 Modified-Checklist for Autism in Toddlers- Revised (M-CHAT-R)

23 The Role of Screening for Autism Our job is to screen, not diagnose Screening positive does not mean that the child has autism Synthesizing other screening results with M-CHAT (reducing surprises) Linkage for further assessment Supporting acquisition of services when indicated.

24 Why Screen? Increasing prevalence of autism (1 in 88) Early aggressive treatment linked to better outcomes ASD can be identified before age 3, but median diagnosis happens after age 4 (later for low SES and minorities) AAP recommends screening at 18 and 24 months

25 What is M-CHAT? A screening tool used for the early detection of Autism Spectrum Disorder (ASD). The ASQ-3 and the ASQ-SE do not specifically screen for symptoms consistent with an ASD. A communication & social delay may be confused with shyness, & behavior in a doctor s office may not represent the child s typical behavior. The goal of the M-CHAT is to detect as many cases of ASD as possible. This results in a high false positive rate. (Robins et al., 2001) With the use of a follow-up interview, the accuracy of screening significantly increases

26 M-CHAT-R Screening Outcomes The majority of cases (92.6%) who completed an M- CHAT-R screened negative. (Prevalence rate is over 1%) More than half (n = 598; 63.2%) of children whose parents completed the follow-up, no longer screened positive. The mean age at evaluation was months (SD: 5.45 months).

27 M-CHAT with Follow-Up Interview Correctly identifies 98% of toddlers with developmental delays 54% of toddlers identified as being at-risk for ASD by the M-CHAT were actually diagnosed with ASD.

28 PSC-35 Ages 4-16 Available in English, Spanish, Haitian Creole Youth Self-Report Form Pictorial Version Online Administration l.org/psychiatry/service s/psc_online.aspx 1988, M.S. Jellinek and J.M. Murphy, Massachusetts General Hospital

29 PSC Online Report Automated summing of Scales - Total Score - Attention Problem - Anxiety/Depression - Conduct Problem Ease of Interpretation Less time scoring means more time for follow-up Other Versions org/psychiatry/service s/psc_forms.aspx

30 Strength & Difficulties Questionnaire (Goodman, 1997) Ages 2-17 Parent, Teacher, and Self-Report (11-17) English and Spanish Online and/or paper administration y/identifiers.py Other versions of SDQ are located at the following: m/

31 SDQ Online Scoring Report Provides qualitative information about child s functioning based on parent, teacher, and/or self-report. Provides percentile categories compared to other children of similar ages Scales - Overall Stress - Emotional Distress - Behavioral Difficulties - Hyperactivity and Attention Difficulties - Difficulties getting along with other children - Kind and helpful behavior

32 Interpreting Screening Results Following up on items of concern may reduce false positives You answered that (Child s name) is (insert behavior). Tell me more about that. The Subjectivity Issue Recent stressful events Validity of Report Teen parents Parents involved in protective services First time parents/isolated parents Parents actively involved with drugs and alcohol Parents with behavioral health difficulties

33 Providing Screening Feedback to Families Always provide feedback regardless of results Highlight child s strengths before communicating areas of concern Be honest and don t minimize Further evaluation usually helps you figure how to be the most helpful to your child If prepared, provide simple and brief tips to provide symptom relief (if possible) Remind screening results are not diagnostic Approach the feedback as a partnering and collaborative process, especially with service navigation

34 Moving from Referral to a Warm Hand-Off Explain to the parent the purpose of the referral and the reasons for following up for additional evaluation Connect the family with the indicated service (not just a piece of paper with a #) If the service is available within the same organization, walk the family over to the appropriate professionals and explain the need for an appointment. Follow-up with family to make sure linkage is complete and stay updated on evaluation/service results. Complete exchange of information for better collaborative care for the child.

35 Possible Follow-up Above Cutoffs Link to Early Steps or FDLRS or school psychologist Link to local community agencies for further evaluation/services Parenting programs Behavioral Health Providers Individual or home-based parenting programs C.A.R.D. Refer to primary health care provider Refer for behavioral health evaluation

36 Referral Issues If the parent/guardian is not willing to accept the referral have parent/caregiver sign documentation acknowledging this. If the child is already receiving services, have the parent sign the form, indicate that the reason is child or parent has already seen (or is currently seeing) a provider regarding concern indicated, and also place a copy of any documentation that the child is already receiving services (e.g. note from OT, Early Steps documentation, etc.).

37 Questions?