Making a Difference for Children
Across North Carolina
School Age and Adolescent
Mental Health Risk Factors
and Screenings
Beth Glueck, MA, LPCS, NCC
Licensed Professional Counselor Supervisor
Marla Satterfield, MA, LPC, NCC
Licensed Professional Counselor
American Academy of Pediatrics
policy statement:
“Pediatric primary care clinicians have unique
opportunities and a growing sense of
responsibility to prevent and address mental
health and substance abuse problems in the
medical home.”
--Committee on Psychosocial Aspects of Child and Family Health and
Task Force on Mental Health
Objectives
• Increase use of screening tools.
• Improve familiarity with tools.
• Learn the appropriate response to
positive screens.
Who are Children and Youth with
Special Health Care Needs
(CYSHCN)?
“ those who have or are at increased risk for a
chronic physical, development, behavioral, or
emotional condition and who also require health
and related services of a type or amount beyond
that required by children generally.”
Defined by the Department of Health and Human Services (HHS), Health Resources and Services
Administration (HRSA), Maternal and Child Health Bureau (MCHB).
Prevalence of CYSHCN
National
• 10.2 million children identified in the United States with
special health care needs.
• 16% are not receiving needed services.
• Majority receive services at physician’s office.
North Carolina
• Over 300,000 children identified as CYSHCN.
• 14.9% are not receiving needed services.
• 46.5 % receive care in a medical home.
Child & Adolescent Mental
Health
• Nationally
– One in four children experience a mental health
condition.
• North Carolina
– NC ranked 32 in the nation for MH services.
– 61.7% received MH treatment in 2007.
NC Prevalence Rates
• Children 6 to 11 years of age
– ADHD: 40.8%
– Depression, Anxiety, and other emotional: 21%
• Adolescents 12 to 17 years of age
– ADHD: 34.8%
– Depression, Anxiety, and other emotional: 26.2%
– Substance abuse: 11% (illicit drugs) 14.3%
(alcohol)
Child & Adolescent Risk Factors
• Family and community factors
–
–
–
–
–
–
Maternal depression
Domestic violence
Trauma
Parental stress
Poverty
Family history of mental health & substance
abuse
Why Use Screening Tools?
• Annual well visit screening on social and
emotional issues leads to:
–
–
–
–
–
Prevention
Early Identification of mental health problems
Aid in establishing appropriate assessment plan.
Referral and treatment to needed services.
Recommended by the AAP Task Force on Mental
Health (TFOMH)
Why Use Screening Tools?
“ Early detection and intervention, particularly in
low-income populations, may prevent or
ameliorate mental health problems in children
and adolescents.”
--The Case for Routine Mental Health Screening
Addressing Mental Health Toolkit
Screening Tools Should Be:
• Validated
• Reliable
• Age appropriate
• Brief
• Culturally considerate
Screening Tools Should be
Used:
• Annual well visits
• Any of the following:
–
–
–
–
–
–
Family disruption
Poor school performance
Recurrent somatic complaints
Involvement of DSS or juvenile justice
Behavioral difficulties
School or family reports psychosocial concerns
Recommended Primary
Screening Tools
• School age (6-10)
– Pediatric Symptom Checklist (PSC)
• Adolescent (11-21)
– Pediatric Symptom Checklist (with Y-PSC)
– Bright Futures Adolescent Questionnaire
– Guidelines for Adolescent Preventive Services
(GAPS)
Pediatric Symptom Checklist
(PSC)
• Psychosocial screen to identify cognitive,
emotional, and behavioral problems for early
intervention.
• Versions: PSC parent completed
Y-PSC youth completed (11 & up)
• Items: 35
• Validity: specificity of .68 and a sensitivity of
.95
• Reliability (test re-test): r=.84 -.91
Pediatric Symptom Checklist
(PSC) cont.
• Positive scores on PSC
– Children ages 4 and 5 = 24 and above
– Ages 6 through 16 = 28 and above
• Positive score on Y-PSC
– Ages 11 and above = 30 or higher
Bright Futures Adolescent
Questionnaire
• Designed to help busy clinicians prioritize
topics to make the most of their time with
patients.
• Optimize visit time, many health care
professionals choose to gather information
while families and patients are waiting to be
seen.
• Pre-visit Questionnaires help practitioners
obtain developmental surveillance
information from parents and youth.
Bright Futures cont.
• Four questionnaires based on developmental
maturity:
–
–
–
–
Older Child/Younger Adolescent
Early Adolescent
15 to 17 Years
18 to 21 Years
Guidelines for Adolescent
Preventive Services (GAPS)
• GAPS is a comprehensive set of recommendations
that provides a framework for the organization and
content of preventive health services.
• Recommendations are organized into 4 types of
services, which address 14 separate topics/health
conditions:
– Delivery of health care services
– Promotion of health and well-being
– Screening for specific conditions common in
adolescents and that cause significant problems.
– Use of immunizations
GAPS cont.
• Screening tools are appropriate for 11 to 21
year olds.
• Three questionnaires available based on
developmental maturity:
– Younger Adolescent Questionnaire
– Middle-Older Adolescent Questionnaire
– Parent/Guardian Questionnaire
• All questionnaires are available in Spanish.
Secondary Screenings
• Suspected Diagnosis:
– ADHD (example: Vanderbilt or Conners)
– Depression (PHQ-A, CDI)
– Anxiety (PHQ-A, SCARED)
– Substance Abuse (CRAFFT)
Patient Health Questionnaire
(PHQ-A) Modified for Teens
• Indicates risk of depression or suicide and is not
a diagnosis.
• Ages: 12 -18
• Items: 13
• Administration: inform patient of confidentiality
and give privacy to complete.
• Scoring: provides a range of depression risk
– A positive response to suicidal ideation or previous
suicidal attempt is a positive screen regardless of the
overall total score.
The CRAFFT Screen
• Recommended by the AAP’s committee on
substance abuse to screen for high risk
alcohol and drug use.
• Ages: 14 and up
• Items: 9
• Positive score: a “Yes” on 2 or more items.
Positive Scores
• Are not a diagnosis.
• Indicate a need for further assessment.
Using Algorithms in Primary Care
• Developed by AAP Task Force on Mental Health to
represent the process primary care providers can
utilize for mental health services in the medical
home.
• Algorithm A promotes social-emotional health,
identifying mental health concerns or symptoms,
child and family involvement in addressing those
concerns or symptoms, and triaging for problems
that require further assessment or referral.
• Algorithm B illustrates the process of assessment
and ongoing care of children with identified socialemotional, mental health or substance abuse
problems.
Algorithm A
Collect and review
pre-visit
data
Provide initial clinical
assessment; observe
child-parent
interactions.
Acknowledge and
reinforce strengths
Visit Scheduled
Algorithm A: Is there a concern?
Return to
routine
health
supervision
Provide
anticipatory
guidance for
age per Bright
Futures,
Connected Kids,
or KYSS
NO
Concerns
(Symptoms, functional
impairment, risk
behaviors, perceived
problems)?
YES
Algorithm A: Decision Making
Concerns?
Collect and
review data from
collateral
sources
YES
Further
diagnostic
assessment
needed?
Proceed to
Algorithm B
Provide
initial
intervention;
facilitate
referral for
specialty
services
Y
E
S
NO
Emergency?
Y
E
S
Facilitate referral
Algorithm B: Assessment
Further
assessment
needed MH/SA
concern
Who will
provide
further
assessment?
Who Provides Assessment?
Primary Care
MH
assessment
Referral to
Child
receiving
MH services
specialist
Who provides
assessment?
Interpret findings to family
(and youth as appropriate);
convey hopefulness about
treatment and recovery
Collect reports and
recommendations
Is Specialty Care Needed?
Implement chronic
care protocol
Specialty
care
needed?
YES
Facilitate
involvement of
specialist
NO
Collaboratively
develop a familycentered plan
Collect reports
and/or convene
team to review
Is Concern Persisting?
Interpret findings to family
(and youth as appropriate);
convey hopefulness about
treatment and recovery.
Return to
routine health
supervision &
monitor for
further issues
YES
NO
Is concern
persisting?
Specialty
care
needed?
Group Activity
A Physician’s View of Screening
• http://www.youtube.com/watch?v=APr0D_OcHc&feature=player_embedded
References
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American Academy of Pediatrics (2010). Addressing mental health concerns in primary care a clinician’s toolkit. Elk Grove
Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. (2009).The future of pediatrics: Mental health competencies
for pediatric primary care. Committee on psychosocial aspects of child and family health and task force on mental
health, Pediatrics, 124, 410-421. Retrieved from www.pediatrics.org/cig/content/full/124/1/410
Bright Futures. http://brightfutures.aap.org/tool_and_resource_kit.html
Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health
Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved [03/03/2010] from
www.cshcndata.org
Drug and alcohol abuse among teens in North Carolina. Retrieved from
http://www.inspirationsyouth.com/TeenRehab- North-Carolina.asp
McPherson, M., Arango, P., Fox, H.B. (1998). A new definition of children with special health care needs. Pediatrics,
102, 137140.
Merikangas, K.R.,He, J., Burstein, M., Swanson, S.A., Avenvoli, S., Cui, L., Benjet, C., Georgiades, K., Swendsen, J.(
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
and Adolescent Psychiatry, 49(10), 980-989.
Sexton, C., Gerald, L., Rager, K.M. (2010). Annual high-quality wellness visits for adolescents: A standard whose
time has come. North Carolina Medical Journal, 71(4),373-376.
State data center, North Carolina. Retrieved from
– http://www.commonwealthfund.org/Maps-and-Data/State-Data-Center/Child-Health/DataByState/State.aspx?state=NC
TeenScreen Capitol Hill Forum: A Physician’s Perspective: Dr. Mason Turner [Video file]. (2010, December 9).
Retrieved from http://www.youtube.com/watch?v=APr0D_OcHc&feature=player_embedded