Minnesota Chapter of the American Academy of Pediatrics

Tom Scott, MD, FAAP

<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/2016/02/CatherineWrightbw150.jpg"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-565" alt="CatherineWrightbw150" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/CatherineWrightbw150.jpg" width="100" height="150" /></a><a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/Glenace-Edwallbw150.jpg"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-563" style="margin-left: 5px; margin-right: 5px;" alt="Glenace-Edwallbw150" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/Glenace-Edwallbw150.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 Catherine L. Wright, PsyD, MS, LPCC, Glenace E. Edwall, PhD, PsyD, LP, MPP, and Tom Scott, MD
Social emotional screening in primary care identifies infants, toddlers, and preschoolers in need of referral for mental health services. This screening process is currently receiving increased clinical and public health attention because of concerns about low rates of detection and treatment of behavioral and emotional problems in the United States.

The CDC (2013) reports that between 13 and 20 percent of children in the United States have a diagnosable mental health disorder in any given year. In addition, childhood trauma not only negatively impacts child development, but also negatively affects the long-term physical, emotional and cognitive health of adults. However, early detection of mental health conditions and early interventions have the greatest potential positive impact on addressing the effects of childhood trauma and mental health development (CSECD-BCYF, 2000).
With children and their families being seen in primary care more than in any other system (Nelson and Schiff, 2015), primary care clinicians have an opportunity to incorporate this component of preventive pediatric care into their practices (Weitzman &amp; Wegner, 2015).
Screening Instrument Resource Info 
To address the issues around social emotional screening in primary care, Minnesota has developed a long-standing interagency screening committee that identifies developmental and social emotional screening tools for young children with appropriate psychometric properties: 
<a href="www.health.state.mn.us/divs/fh/mch/webcourse/devscrn/instrument.cfm//" target="_blank" rel="noopener">www.health.state.mn.us/divs/fh/mch/webcourse/devscrn/instrument.cfm</a>
Selection of Screening Instruments 
Clinics should use social emotional screeners that have strong psychometric properties – sensitivity and specificity .70 or greater (Glascoe, 2014).
Parent Completion of Screening Information 
Clinics are advised to use electronic screening that may occur in the waiting room or by the family prior to attending the primary care visit to save time, money and scoring issues (Wright &amp; Holm-Hansen, 2010). For families who do not read English, screenings should be conducted with an interpreter trained in and knowledgeable about the tool (Glascoe, 2014).
Online Pilot 
Minnesota is piloting electronic screening and the use of audio versions of screenings in Hmong, Somali, English and Spanish. More information about the electronic screening project is available at: <a href="http://www2.ed.gov/programs/racetothetop-earlylearningchallenge/annual-performance-reports/mn2013apr.pdf" target="_blank" rel="noopener">http://www2.ed.gov/programs/racetothetop-earlylearningchallenge/annual-performance-reports/mn2013apr.pdf</a>
Minnesota System of Care 
Minnesota has developed an early childhood mental health system of care to assist primary care referral based on agencies that employ highly trained mental health professionals in the areas of early childhood mental health assessment and treatment; these agencies currently serve young children. A map of these agencies is available at: <a href="https://edocs.dhs.state.mn.us/lfserver/Public/DHS-5448D-ENG" target="_blank" rel="noopener">https://edocs.dhs.state.mn.us/lfserver/Public/DHS-5448D-ENG</a>
Successful Referrals 
Families are more likely to follow through on referrals when a care coordinator within the clinic system is available to assist the family (Talmi et al., 2014).
Steps to Implement Screening
<ul>
<li>Reading the practice</li>
<li>Identifying resources</li>
<li>Establishing office routines for screening and surveillance</li>
<li>Tracking referrals</li>
<li>Seeking payment</li>
<li>Fostering collaboration</li>
</ul>
Social emotional screening in primary care has the potential to identify early onset mental health conditions and address childhood trauma more than in any other system. Social emotional screening must include the use of standardized tools with acceptable psychometric properties. Electronic screening tools have been found to save on costs, time, and eliminate scoring errors. Additionally, all screening efforts must include a referral system to competent mental health assessors and intervenors. Referral systems using care coordinators are a sound means for ensuring that families have access to the care they need.
References available upon request. Email debilzan@mnaap.org

Social Emotional Screening in Early Childhood

By Tom Scott, MD, FAAP, Interim Director, Developmental-Behavioral Pediatrics Residency Program, University of Minnesota
The care of all infants, children and adolescents involves Developmental-Behavioral Pediatrics (DBP), whether by primary pediatricians or DBP specialists. Composing a relatively new sub-specialty, DB pediatricians provide care for a range of patients with developmental, learning, emotional, and behavioral disorders. Similar to primary care pediatricians, DB pediatricians also focus on healthy child and adolescent development, identifying strengths, promoting resilience, and reducing risk.
DB pediatricians work as individual consultants or in teams. Team members from other disciplines may be on site or in the community and include speech and language pathologists, audiologists, psychologists, nurses, education specialists, occupational therapists, physical therapists, nutritionists, neurologists, geneticists, and child psychiatrists. Sometimes primary care pediatricians consult directly with these other team members.
Whether a patient should be referred to a DB pediatrician, a child psychologist, or child psychiatrist and whether to an individual consultant or to a team depends on the nature and complexity of the problem and availability of specialty resources. Sometimes a referral to a person on the team will result in a recommendation for additional assessment by other team members. There may be overlap in the clinical expertise of specialists on the team, and in complex cases, additional perspectives may be particularly helpful diagnostically. DB pediatricians in Minnesota have varying areas of specialization, including autism, early childhood issues, ADHD, learning disorders, Down’s syndrome, sleep, self-regulation, and hypnosis. Also, some general pediatricians have special interests in DBP and serve as resources for other clinicians.
The following are general guidelines in making referral and consultation requests to DB pediatricians, child psychologists, and child psychiatrists:
Referral/consult request to Developmental-Behavioral pediatrician: 
&#8211; Complicated school learning,attention, and behavior problems 
&#8211; Questions of autism spectrum diagnosis and management 
&#8211; Anxiety and depression 
&#8211; Persistent somatic symptoms 
&#8211; Persistent elimination and soiling problems 
&#8211; Sleep issues
Referral/consult request to child psychologist: 
&#8211; Questions of co-morbidity with learning and attention problems 
&#8211; Questions of cognitive status 
&#8211; Differential diagnosis of anxiety, depression, behavioral issues 
&#8211; Questions of autism spectrum diagnosis and management 
&#8211; Individual or family therapy 
&#8211; Cognitive behavioral therapy
Referral/consult request to child psychiatrist: 
&#8211; Out of control behavior 
&#8211; Suicidal issues 
&#8211; Questions of bi-polar disorder 
&#8211; Questions of psychosis
Pediatricians in Minnesota, like those throughout the country, have concerns about the availability of DB pediatricians and long waiting lists. At present, almost all DB pediatricians in Minnesota are located in the metro area. A recent study found 86 percent of primary care pediatricians in the United States reporting too few DB pediatricians and 95 percent reporting too few child/adolescent psychiatrists to meet the needs of patients in their practices. In 2011 only 35 first-year DBP fellows were in training in the United States.
In order to address the shortage of DB pediatricians, advocacy at a federal, state and local level is essential.
References: 
The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, Third Edition, Marilyn Augustyn, Barry Zuckerman, Elizabeth B. Caronna, editors, 2011. 
Encounters with Children, Pediatric Behavior and Development, Fourth Edition, Suzanne D. Dixon and Martin T. Stein, 2006 
Primary Care Pediatricians’ Satisfaction with Subspecialty Care, Perceived Supply, and Barriers to Care, Journal of Pediatrics, 2011, Vol. 156, No. 6,1011-1015

What is Developmental-Behavioral Health Pediatrics?

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Tom Scott, MD, FAAP Category