Minnesota Chapter of the American Academy of Pediatrics

Andrew Barnes, MD, MPH

<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/AndyBarnesbw1501.jpg"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-560" alt="AndyBarnesbw150" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/AndyBarnesbw1501.jpg" width="100" height="150" /></a><a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/TomScott1.gif"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-561" style="margin-left: 5px; margin-right: 5px;" alt="TomScott" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/TomScott1.gif" width="100" height="150" /></a>By Andrew J. Barnes, MD, MPH, Assistant Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota and Tom Scott, MD, Clinical Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota
Although there are normative challenges during childhood – for example, separating from parents for daycare – many children experience frequent or ongoing stress that is overwhelming. Such stress, including Adverse Childhood Experiences (ACEs) and extreme poverty, can lead to modified gene expression, problems with cognitive and social-emotional development, and chronic health conditions. These negative outcomes are less likely for children with ample protective factors, whether internal (such as self-regulation) or external (such as a consistent, nurturing adult caregiver). These factors improve children’s capacity to succeed and develop well in the context of threat or challenge – i.e., resilience.

Recognizing this, the AAP’s 2006 policy statement on developmental-behavioral screening and surveillance in the medical home recommends that clinicians identify risk and protective factors for all children and families in their care. However, in a 2013 survey, one-third of AAP members never inquired about these factors; of those who usually did inquire, most did so only for maternal depression or parental separation. Other common ACEs &#8212; such as parental alcohol/drug use, domestic violence, and parental incarceration – were rarely screened for or discussed. Indeed, to date there is scant evidence about how and when to best do so.
As we await such evidence and further guidance, there are several tools that pediatric clinics can use right now to fully implement the AAP’s recommendations. One such tool, the Family Psychosocial Screen, is available for free from AAP Bright Futures (<a href="http://brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf" target="_blank" rel="noopener">http://brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf</a>). This 2-page form includes home safety, parent depression, substance abuse, domestic violence, parent abuse history, socioeconomic factors, and social supports.
Another free tool, the Survey of Well-Being for Young Children (<a href="http://theSWYC.org" target="_blank" rel="noopener">http://theSWYC.org</a>), is a one-page broadband developmental-behavioral screen for children 0 to 5 that includes brief, well-validated psychosocial screening measures for parent depression, substance abuse, food insecurity, and domestic abuse.
Some primary care clinics are beginning to adapt the original 10-item ACEs questionnaires (for children and their parents), administered either anonymously (i.e., parents tally their own score, 0-10, and report only the total score to the clinician), by interview, or on paper; a cut-off score of 4 is usually recommended for referral, based on the initial ACEs studies among adults. The AAP clinical report, Promoting Optimal Development: Screening for Behavioral and Emotional Problems (2015), includes an ACE screening resource, as well as a Resilience scale that can help clinicians provide effective parent education and anticipatory guidance in primary care settings &#8212; both of particular interest to pediatricians developing this emerging and highly important area of clinical practice (both screens available at <a href="http://acestoohigh.com/got-your-ace-score" target="_blank" rel="noopener">http://acestoohigh.com/got-your-ace-score</a>).
As pediatric clinicians we are well positioned to sensitively ask about risk and protective factors for the children we serve – whether with a formal screening tool, routine surveillance, or (ideally) both. Doing so enables us to prevent harm and promote health by reinforcing current areas of strength and resilience; bolstering protective factors that are limited or absent; and reducing risk through intervention when needed.

Screening for Adverse Childhood Experiences, Psychosocial Risk, and Resilience

<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/08/AndyBarnes.jpg"><img decoding="async" class=" wp-image-493 alignleft" style="margin: 5px;" alt="AndyBarnes" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/08/AndyBarnes.jpg" width="115" /></a>By Andrew Barnes, MD , MPH, FAAP, Assistant Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota
If you’ve ever wondered whether you’re seeing more children with disabilities in your clinic over the past 15 years, you are – from 2000-2010, this population of children grew the fastest since it started to be recorded in the U.S. This increasing prevalence was mostly due to neurodevelopmental differences and mental health conditions – up 20% in the past decade (while physical health disabilities were down 10%), rising fastest among families with higher socioeconomic status. We may be identifying some of these children better in our clinics because of improved standardized developmental screening, as recommended by the American Academy of Pediatrics in their 2006 policy statement. This policy (and other related policies relating to autism, social-emotional, and mental health screenings) recognize that early intervention is critical for children with developmental and behavioral needs, and that these conditions are best managed within a medical home that cares for the whole child.

Growing evidence suggests that clinicians are well positioned not just to perform surveillance at every well child visit and formal developmental screening only at select visits, but moreover to fully implement screening for risk and resilience across childhood and adolescence. This includes:
<ul>
<li>Developmental and behavioral screening from birth to school-age</li>
<li>Autism screening for toddlers</li>
<li>Maternal depression screening during the newborn period and infancy</li>
<li>Social-emotional and mental health screening for toddlers, preschoolers, school-age children and adolescents</li>
<li>Adverse childhood experiences, psychosocial risk, and protective factors for all children and teens</li>
</ul>
Although it can seem daunting to integrate and sustain such screenings in clinical practice, practical advice for systematically doing so is available at <a href="DBPeds.org">DBPeds.org</a> under the “Practice Management” tab.
Feasibility issues to consider when selecting screening tools include whether the tool has established validity and reliability for diverse populations; ease of scoring and interpretation; literacy level of the tool; whether translated versions or culturally-neutral versions of the tool exist; costs of the tool and the time to administer and score it; and the method of delivery and scoring (paper/pencil, tablet computer, online kiosk).
Practice considerations include defining when and where the tool is given (before, during, or after the visit), who administers and scores it, and how completion rates and quality will be monitored.
Coding and billing should take into account that the Centers for Medicare and Medicaid Services changed the Current Procedural Terminology (CPT) codes for these screenings in early 2015. The prior CPT code that covered all such screenings, 96110, is now to be used only for “physical development” such as milestone-oriented surveys and speech and language screenings.
A new CPT code, 96127, is to be used for emotional and behavioral screenings (such as those used for ADHD, mental health, substance abuse, or psychosocial risk). Both of these codes can be billed in multiple units; for example, if a child has two parents who both complete an autism checklist screening tool to provide multiple perspectives, then 96110 should be billed x2 units for that visit. These CPT codes are intended to cover the office costs associated with their administration (e.g., nursing assistant time and the cost of obtaining the survey), not for clinician time and effort, which are included in the Evaluation and Management code for that visit.)
Methods for screening the five areas mentioned above will be covered in this newsletter in more detail in the coming issues. Understanding how and why to use these screening methods can help us engage with our patients, practice community, and systems of care to improve how we care for the whole child.

Screening Instruments: Caring for the Whole Child

Grand Itasca Clinic & Hospital is seeking a board certified/board eligible outpatient Pediatric Physician to join our busy and growing primary care clinic practice. Grand Itasca is a fully integrated multi-specialty clinic and hospital located in Grand Rapids, Minnesota.

Pediatric Physician

Partners in Pediatrics, Ltd. is seeking a full time BC/BE Pediatrician. The standard work week for a full-time pediatrician is 4 days a week plus a rotation of nights and weekends. Night and weekend shifts are shared equally among all providers. The salary package is competitive. You will have paid time off (PTO) and be given a CME allowance as well as CME days to further your medical education. We offer health, dental, disability and life insurance. You will also be eligible for a lucrative profit sharing 401(k). For inquiries, please contact our recruiting leads, Dr. Lisa Irvin at lirvin@pipstop.com and Dr. Megan Camerino at mcarmerino@pipstop.com

BC/BE Pediatrician

We’re excited to announce an opening for a Communications Manager at the Minnesota Chapter of the American Academy of Pediatrics (MNAAP). This part-time, remote role is a unique opportunity for a communications professional with at least five years of experience, who is passionate about advancing child health through advocacy, education, and special projects.

Andrew Barnes, MD, MPH Category