Minnesota Chapter of the American Academy of Pediatrics

Behavioral Health

<h3 class="wp-block-heading">What is a work group?</h3>



The MNAAP work groups were formed as part of the chapter’s strategic priorities plan to address areas in which change or improvement would benefit the lives of Minnesota’s youth. During a work group meeting, members often identify opportunities for collaboration, potential projects to take on, or other ways to advocate for their cause. Email Bethany Venable (venable@mnaap.org) for more information.



Anti-Racism &amp; Disparities



The Anti-Racism &amp; Disparities work group is looking ahead to spring with plans to host a retreat to bring members together in an energizing session of planning and visioning. The group is also the chapter’s point of contact for a new contract initiated with the YWCA to help further embed diversity, equity, accessibility and inclusion in the MNAAP culture and operations. The Anti-Racism &amp; Disparities Work Group next meeting is set for Monday, Dec. 11, from 12:15 to 1 p.m. via Zoom.



Early Childhood



It has been a monumental year for investment in the littlest Minnesotans, thanks in part, to all the MNAAP members who spoke up for children who can’t speak for themselves. Yet, all this positive change yields more opportunity and more work to do! This year, our chapter will have monthly meetings or lectures about the ways we can advocate at the policy level for prenatal to five health and investment. We will also talk about how we can bring important programming into our daily practice. Our next meeting is Oct. 27, at 12:10 p.m. via Zoom.&nbsp; If you believe in the power of the first 1,000 days to change a life course, then please join us!



Behavioral/Mental Health



The Behavioral/Mental Health work group continues to work on the Minnesota Pediatric Mental Health Access Program MOC 4 focused on depression screening in LGBTQ+ and BIPOC communities. We are looking forward to learning more about how we can have open, affirming screening and supportive conversations around mental health from the youth in our community partnerships. 



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MNAAP Work Group News | Fall 2023

MNAAP is seeking clinics to participate in a MOC4 quality improvement project aimed at improving documentation and administration of depression screening and referral of teens who identify as BIPOC and/or LGBQI+. Up to 25 MOC4 credits are available for participating physicians.



According to Minnesota Community Measurement, half of all lifetime cases of mental illness begin by age 14. Anxiety disorders are the most common mental health condition among young people, particularly BIPOC and LGBTQI+ youth. But many young people&nbsp;are never&nbsp;treated&nbsp;&#8211; or not until they&#8217;re in crisis.&nbsp;



This MOC4 module seeks to improve adolescent mental health screening rates at adolescent and young adult clinic visits using the HEDIS and Minnesota Community Measurement measures, as well as by integrating feedback from BIPOC and LGBTQI+ youth into the development of more culturally sensitive/relevant screening tools. Each participating clinic receives $4,000 to support QI-related activities.



The project runs from May through August. For more information, contact MNAAP Executive Director&nbsp;<a href="mailto:bauer@mnaap.org" target="_blank" rel="noreferrer noopener">Jeff Bauer.</a>

Earn 25 MOC4 Credits Through Adolescent Mental Health Screening and Referral Project

The Minnesota Department of Health (MDH) would like to have a better understanding of the need for and resources available to respond to mental health concerns in children and adolescents.



As part of this work, MDH has hired Wilder Research to conduct surveys and key informant interviews with pediatric care providers to gain better insight. MDH is interested in how two resources can be better integrated and improved to align with the needs of patients and providers in Minnesota.



Your feedback will help improve the experiences of other health care providers seeking assistance with youth mental health consultations.



Wilder Research is interested in talking with you about your experience as provider in your community, understanding mental health resources and the underutilization of specific resources to better address mental health. They also interested in recommendations for how to make these resources more available and accessible.



If you are available for a 30-45 minute interview, please sign up for a time slot at <a href="https://slotted.co/mdhpalft﻿" target="_blank" rel="noreferrer noopener" aria-label="https://slotted.co/mdhpalft (opens in a new tab)">https://slotted.co/mdhpalft</a>. If you are unavailable for an interview, but know of another pediatric provider that may be interested, please pass this email on to them.



We appreciate your time and the information you share!

Help Improve Mental Health Consultation Experiences

Sam Marzouk, PhD, LP



An alarming trend has emerged over the past decade.&nbsp; A growing number of adolescents are seeking treatment for depression.&nbsp; Jean Twenge, a researcher at San Diego State University, found that between 2005-2017 there was a 52 percent increase in the rate of major depressive disorder among adolescents aged 12-17.&nbsp; There was a 63 percent increase in depression among those aged 18-25 during the period 2009-2017.&nbsp; Many have interpreted this trend through a lens of optimism, seeing it as evidence that the stigma around mental illness is abating, and adolescents are now more willing to seek professional help for symptoms.&nbsp; Others cannot help but notice the suspicious timing of this spike in adolescent depression with the ubiquity of social media and smartphone usage.&nbsp; Researchers across multiple disciplines have examined the relationship between social media and adolescent mental health.&nbsp; While there’s much we do not know, we are slowly starting to shed light on the deleterious impact social media usage can have on the well-being of our teenagers.&nbsp; 



There are likely multiple
etiological factors that explain the recent rise in adolescent depression.&nbsp; However, the evidence establishing a link
between social media and adolescent depression is too powerful to ignore.&nbsp; Most research has examined the impact that
mere “time” on social media has on adolescent depression.&nbsp; For example, Keles’s 2020 meta-analysis
synthesizing the evidence of 13 studies found a modest but statistically
significant relationship between time spent on social media and increased
depression.&nbsp; The daily amount of time
spent on social media has been closely examined, with most studies finding that
two or more hours a day is strongly correlated to increased depression symptoms.&nbsp; The effects of light social media usage (i.e.,
less than one hour a day), on the other hand, are less clear.&nbsp; Nearly all research with older adolescents
suggests that light social media usage does not lead to poorer mental health
outcomes, with some findings suggesting light usage may even offer psychosocial
benefits such as increased social connection to peers.&nbsp; Among preteens and younger adolescents, there
is a noticeable lack of research examining effects of light social media
usage.&nbsp; While there is little debate
regarding the negative effects of heavy social media use on adolescent mental
health, this conclusion offers little clinical utility for practicing
clinicians.&nbsp; The nagging question remains:
what is it about social media that may cause depression in teenagers? 



Studies have begun to look beyond the
effects of mere time spent on social media platforms.&nbsp; For example, a small number of studies have
explored the differing effects of social media usage by age.&nbsp; There is strong evidence to suggest that
preteens and younger adolescents are far more vulnerable to the negative
impacts of social media compared to older adolescents.&nbsp; Bullying often peaks during the preteen years,
with smartphones and social media providing a 24/7 bullying platform.&nbsp; Even without bullying, early adolescence is a
fragile and malleable time for identity development, with younger teens less
likely to question the distorted realities presented on social media. &nbsp;While light social media use may be beneficial
for older adolescents, there is no evidence suggesting this finding is
generalizable to younger adolescents.&nbsp; Gender
has also emerged as another key variable with social media negatively affecting
adolescent girls far more than boys.&nbsp; Finally,
some research has looked at how specific social media behaviors influence
mental health outcomes.&nbsp; Nesi and
Prinstein (2015) found that adolescents who use social media more for social
comparisons and reassurance seeking (e.g., posting a capture with the
caption, “Do I look pretty today?”) tended to report higher depression symptom
severity.&nbsp; 



The wheels of science move slowly,
and there is much more to unpack in this area.&nbsp;
It may be a while before we get to the truth regarding social media and
adolescent mental health.&nbsp; Considering
what we currently know, I’ve assembled the following working list of
recommendations for parents regarding teens and social media use.&nbsp; I plan to regularly update my recommendations
as new research is published. 



<ol class="wp-block-list"><li>No social media until high
school.&nbsp; Period.&nbsp; As described above, there is strong evidence
to suggest that younger adolescents and preteens are most vulnerable to the
negative effects of social media.&nbsp; While
this may be pragmatically difficult to implement, the evidence is clear that
children younger than 15 are at the highest risk. &nbsp;&nbsp;</li><li>If adolescents under 15 are on
social media, limit usage to less than one hour per day.&nbsp; For older adolescents limit usage to less
than two hour per day.&nbsp; While total time
on social media is only one variable of interest, it’s allowed us to see how heavy
use can be particularly detrimental to adolescent mental health. </li><li>There should be no social media
usage within one hour before bedtime.&nbsp; The
evidence suggests that social media usage can lead to delayed sleep onset and
decreased total sleep time, thereby fueling the development of depression
symptoms.&nbsp; &nbsp;</li><li>At first, allow teenagers to access
platforms that place a stronger emphasis on social connection (e.g.,
social discord, reddit, snapchat) versus social comparison (e.g.,
Instagram).&nbsp; We have learned through
research how social media platforms can amplify an adolescent’s pre-existing
tendency to engage in upward social comparison.&nbsp;
Furthermore, we know that one of the few reasons why light social
media use can be beneficial for mental health is that it affords the
opportunity for adolescents to feel more socially connected.&nbsp; </li><li>Monitor social media
behaviors.&nbsp; As discussed, time on social
media is just one piece to this complicated puzzle.&nbsp; What the adolescent is doing on social media
may be more important.&nbsp; I advise parents
to closely monitor social media use and keep a particularly close eye on
behaviors such as reassurance and feedback-seeking that have been found to be
associated with depression. &nbsp;</li></ol>



While we have learned much about social media and the possible harmful impact it may have on adolescents, there are still gaps in the literature and key questions unanswered.  Future research should consider comparing the effects of various social media platforms.  It would also be helpful to gain more insight into how specific social media behaviors influence mental health (e.g., number of posts per day, etc.)  Shedding light on the nuances behind total time spent on social media will help develop more insightful and robust recommendations.  Finally, as with any relationships between two variables, there are exceptions and outliers.  It would be helpful to better understand what protective factors could serve as a buffer for adolescents against the harmful effects of social media.  At the end of the day, social media is here to stay and it’s our job to help teenagers use it responsibly and minimize its many risks.  



About the Author



Sam Marzouk, Ph.D., L.P. is a pediatric psychologist and owner of Promethean Psychology in Edina, Minnesota. A strong advocate for evidence-based psychology, Dr. Marzouk is passionate about translating research into clinical practice to empower children, adolescents and families.

Social Media and Adolescent Mental Health: What We Actually Know

The Minnesota Department of Health (MDH) would like to have a better understanding of how providers screen and respond to mental health concerns in children and adolescents. As part of this work, MDH has hired <a href="https://www.wilder.org/wilder-research" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.wilder.org/wilder-research&amp;source=gmail&amp;ust=1660746826187000&amp;usg=AOvVaw3dUeI1KAfS3WksTrPxWV5I">Wilder Research</a> to conduct a survey of health care providers. Specifically, MDH would like to know if providers have heard of, or have used, two behavioral health care resources: the Psychiatric Assistance Line (PAL) and Fast Tracker.
The Psychiatric Assistance Line (PAL) is a free service that any healthcare provider can call for mental health triage and referral, or for a consultation with a Board Certified Child and Adolescent Psychiatrist regarding a patient. Fast Tracker is a web-based directory of mental and substance use disorder resources in Minnesota.
Even if you are not familiar with these resources, we would still like you to take the survey.
Please click <a href="https://us1se.voxco.com/SE/1145/PALFastTrackerSurvey/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://us1se.voxco.com/SE/1145/PALFastTrackerSurvey/&amp;source=gmail&amp;ust=1660746826187000&amp;usg=AOvVaw0te8Y_WjesN_8fb3jmp-or">https://us1se.voxco.com/SE/1145/PALFastTrackerSurvey/</a> to take the survey. The survey should take between 5-10 minutes, depending on how you answer.
Your feedback will help improve the experiences of other health care providers seeking assistance with youth mental health consultations. If you have any technical questions or would like to request accommodations for this survey, please email Kyla Goux at Wilder Research (<a href="mailto:kyla.goux@wilder.org" target="_blank" rel="noopener noreferrer">kyla.goux@wilder.org</a>). If you have any questions about this evaluation, please email Sarah Mapellentz at MDH (<a href="mailto:sarah.mapellentz@state.mn.us" target="_blank" rel="noopener noreferrer">sarah.mapellentz@state.mn.us</a>).
Thank you for your participation!

MDH Seeks Provider Feedback About Behavioral Health Care Resources

By Rachel Tellez, MD, pediatrician at HCMC
<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/05/Rachel-Tellez-2-1.jpg"><img loading="lazy" decoding="async" class="size-thumbnail wp-image-575 alignright" style="margin: 5px;" alt="Rachel Tellez 2-1" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/05/Rachel-Tellez-2-1-150x150.jpg" width="150" height="150" /></a>Nearly 15 percent of Minnesota’s children live in poverty, with children of color being disproportionately affected: nearly half of African-American children, one-third of American Indian children, one-third of Hispanic children, and one-fifth of Asian children live in poverty. Living in poverty can result in poorer health outcomes for children, including negative effects on physical health, nutritional status, socioemotional development, language development and educational outcomes. Additionally, more than one-third of Minnesota children (419,000) live in low-income households that struggle to provide basic needs and opportunities resulting in similar long-term outcomes, according to Kids Count.

The March 2016 AAP policy statement “Poverty and Child Health in the United States” recommends that pediatricians advocate for families on the clinic, local, and national levels: “Pediatricians have the opportunity to screen for risk factors for adversity, to identify family strengths that are protective against toxic stress, and to provide referrals to community organizations that support and assist families in economic stress.” Recognizing the needs of children in poverty and the challenges faced by pediatricians, Minnesota AAP members have asked the MNAAP to help identify resources to assist pediatricians in helping these families.
One potential resource to help low-income families is the “Bridge to Benefits” free online screening tool <a href="http://www.mn.bridgetobenefits.org">mn.bridgetobenefits.org</a> developed by the Children’s Defense Fund-Minnesota (CDF-MN). After entering information about family size and income, the screening tool determines potential eligibility for a number of public work support programs, including Medical Assistance, MinnesotaCare, Child Care Assistance, Energy Assistance, Supplemental Nutrition Assistance Program (SNAP), School Meals, WIC, as well as some tax credits. The website does not actually enroll families in these programs, but refers them to county-based organizations that can then follow-up to assist with the application process.
Elaine Cunningham, Outreach Director for CDF-MN, explains that the website was developed “to improve the economic stability of low income families by enrolling them in an array of public work support programs.” Economic stability is important, she says, because even small increases in a family’s income is linked to improved educational, health, nutritional and behavioral outcomes in children. Thousands of Minnesota families are eligible but not enrolled in these important support programs, she adds, mainly due to the multiple barriers families face in applying: complex application processes, differing eligibility rules, stigma, and literacy, and language. In 2015 there were 37,000 Bridge to Benefits screens completed, covering 106,000 family members.
The Bridge to Benefits website is worth a visit by every pediatrician, at the minimum for educational purposes. In addition to the screening tool, there are descriptions of all the programs such as “What is SNAP” or “What is Energy Assistance,” as well as more specific information such as how immigration status affects eligibility for the programs. There is also a “Find Other Help” section that includes additional resources on disability services, early childhood education, employment, housing, etc. 
While the online screening tool is designed to be quick and easy, it may still prove a bit cumbersome for some families. CDF-MN recommends training clinic staff to help navigate the screening tool with patients. Once staff are familiar with the tool, it takes about 5 minutes to enter the information and get results on which programs a family may be eligible, the approximate benefit amount the programs will provide, and which local organizations can assist with the application processes.
More than 300 organizations in Minnesota use the screening tool, yet few are medical clinics. Bridge to Benefits could be a valuable tool in helping to address the effects of poverty on pediatric patients and families. Please consider contacting Elaine Cunningham ecunningham@childrensdefense.org to discuss best practices for implementing Bridge to Benefits in a variety of health clinic settings or to set up a training for your organization.
Thank you to Elaine Cunningham for her contributions to this article.
&nbsp;

Screening Tool for Low-Income Families: Bridge to Benefits

<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

<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/HelenKim.jpg"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-536" alt="HelenKim" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/HelenKim.jpg" width="100" height="150" /></a><a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/headshot-tessa1.jpg"><img loading="lazy" decoding="async" class="alignleft size-full wp-image-567" style="margin-left: 5px; margin-right: 5px;" alt="headshot-tessa" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2016/02/headshot-tessa1.jpg" width="100" height="150" /></a>By Helen Kim, MD, Director of the HCMC Mother-Baby Program, and Tessa Wetjen, Minnesota Department of Human Services
The AAP has clearly stated that pediatricians must lead efforts to reduce the impact of toxic stress on children given the lifelong impact of adverse childhood experiences on physical and mental health.
Postpartum depression occurs in 10 to 35 percent of mothers (Berkule, et al., 2014) and poses a significant risk for toxic stress in children by undermining a mother’s ability to provide the nurturing interactions children need for healthy development. Children of depressed mothers or fathers are more likely to perform lower on cognitive, emotional and behavioral assessment (Berkule, et al., 2014) and have increased risk of mental health issues later in life (Ferro &amp; Boyle, 2015).

Screening for postpartum depression within a baby well-child check can be relatively simple and lead to improved care for the child and family. The Minnesota Department of Health (MDH) has compiled resources to make maternal depression screening meaningful for patients and families and simple and reimbursable for pediatric practices.
The MDH comprehensive guide includes background information; timeline for well-child visit screening; algorithm of interventions for high scoring mothers; guidance on documenting the score and billing for the service; and patient and provider resources. The screen can be done using a free tool (either the <a href="http://www.cqaimh.org/pdf/tool_phq9.pdf" target="_blank" rel="noopener">PHQ-9</a> or <a href="http://www2.aap.org/sections/scan/practicingsafety/toolkit_resources/module2/epds.pdf" target="_blank" rel="noopener">EPDS</a>) and scored by rooming staff. The pediatrician can provide mom with appropriate intervention based on the score and document. The screen is billable, if the tool used is the PHQ-9, EPDS, or Beck. There are a number of ways to document the score and follow up, which should include regular social-emotional screening for the child, detailed in the <a href="http://www.health.state.mn.us/divs/cfh/topic/pmad/content/document/pdf/ppdguide.pdf" target="_blank" rel="noopener">clinical guidelines</a>.
MDH has a <a href="http://www.health.state.mn.us/divs/cfh/topic/pmad/pmadfs.cfm" target="_blank" rel="noopener">fact sheet</a> on perinatal mood and anxiety disorders and a “<a href="http://www.health.state.mn.us/divs/cfh/topic/pmad/pmadfs.cfm" target="_blank" rel="noopener">Maternal Wellbeing Plan</a>” for mothers of infants.
For support in implementing PPD screening in pediatric practices, contact Tessa.Wetjen@state.mn.us or 651-201-3625
References available upon request. Email debilzan@mnaap.org

Postpartum Depression Screening in Pediatrics made Meaningful, Simple and Reimbursable

By Michael Reiff, MD, FAAP
<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/11/michaelreiff.jpg"><img loading="lazy" decoding="async" class="size-thumbnail wp-image-527 alignleft" style="margin: 5px;" alt="michaelreiff" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/11/michaelreiff-150x150.jpg" width="150" height="150" /></a>With the current prevalence of autism spectrum disorder (ASD) estimated at 1 in 68 children and rising, it is imperative that pediatricians take an active and informed role in identifying children at risk. Despite a great deal of effort regarding early identification, parents generally report initial concerns before their child is 18 months and still the average age of diagnosis remains at about 4-5 years of age. It is important that screening tools used by pediatricians be as evidence based as possible to avoid over- or under-referral for diagnosis.

The current AAP guidelines recommend ASD screening at 18 and 24 months. This recommendation is prudent in spite of some current controversy about the efficacy of screening children whose parents have not voiced concerns. We have evidence that we are already missing children at risk for ASD with present recommendations and procedures, and stopping screening would be likely to compound this and be a step backwards. Universal screening for ASD can streamline the early detection process and facilitate appropriate referrals.
General screening tools familiar to pediatricians such as the Ages and Stages Questionnaires (ASQ), Communication and Symbolic Behavior Scales (CSBS), and Parents’ Evaluation of developmental Status (PEDS) can all be helpful in identification of children at risk for developmental and language delays but are not specific to ASD screening.
Some of the more familiar ASD screening tools include the Modified Checklist for Autism in Toddlers (MCHAT), which is a parent completed questionnaire, and the Screening Tool for Autism in Toddlers and Young Children (STAT), an interactive screening tool designed for children in whom developmental delays are suspected.
The Modified Checklist for Autism in Toddlers, Revised (MCHAT-R), with Follow-up interview (M-CHAT-R/F) is one of the most used and researched screening tools. The original M-CHAT produced an unacceptably high false positive rate (the number of children who screened positive but were not found to have ASD on careful evaluation), even when a follow-up interview was added. The M-CHAT-R/F was developed in order to reduce the false positive rate and detect more ASD cases. The MCHAT-R scoring is simplified from the original MCHAT and contains an algorithm that separates low-risk, moderate-risk and high-risk scores. The M-CHAT-R follow-up interview is essential for moderate-risk scores because a it yields a dramatically increased positive predictive value (PPV) when both stages are implemented. In addition, using this new protocol, the PPV for any developmental disorder using the M-CHAT-R/F is .946, indicating that a high percentage of children screening positive by this procedure need evaluation and intervention. Scores on the M-CHAT-R/F can range from 0-20.
<ul>
<li>Those with low risk scores (0-2) can continue with developmental surveillance without the follow-up interview or referral.</li>
<li>The follow-up interview should be administered to those at moderate risk (3-7), and, if the interview yields positive scores (2+), children should be referred for evaluation and early intervention.</li>
<li>Those with high-risk scores (8-20) can bypass the follow-up interview and should be immediately referred.</li>
</ul>
One of the key issues in ASD screening is early detection to assure that identified children who receive the ASD diagnosis receive intensive early evidence-based interventions as soon as possible. In the past few years there have been many advances in detecting the early signs of ASD. These findings indicate that there is substantial heterogeneity in the presentation of ASD.
Some early markers of ASD between 12 and 24 months include reduced levels of social attention and social communication as well as repetitive behaviors with atypical body movements and motor development. Temperament observations around age 2 can include lower sensitivity to social rewards as well as negative affect and difficult behaviors. Helpful behavioral markers below 1 year of age have not been constantly identified. Language development and/or non-verbal cognitive gains may slow down after the first year. From 6-18 months gaze to faces, vocalizations directed toward people and social smiling may decline.
In light of this research we are now in a good position to start developing tools to measure these behaviors in clinical practice using observations and parent reports.
References available upon request.

Screening Instruments: Autism Spectrum Disorders

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Behavioral Health Updates