Primary Care Pediatric Psychology

W. Douglas Tynan, Ph.D., ABPP

For copies please email:Dtynan@nemours.org

Overview

Why offer mental health services in primary care?

What does primary care pediatric psychology look like?

Establishing a primary care psychology program– Training issues– Business considerations– Coordinated vs. integrated care

Training pediatricians to assess and treat child mental health problems

Unmet Needs for Parent Support & Guidance in Pediatric Care

Nemours Pediatric Needs Assessment

Needs Assessment, August 30, 2001 (18 of 30 providers for 9 offices of duPontPediatrics; 40,000 patients served statewide).

Providers were asked to list the 3 most common reasons for types of problems, 3 ratingsin each category:

1. Health Care Needs – Reasons for Visits: Providers were asked to list their top 3reasons for why children come to their office.

31/54 (57%) Acute illness such as otitis media or URI17/54 (31%) Behavior at home, school behavior, or academic problem6/54 (11%) Health maintenance (annual physical)

2. Emotional/Behavioral/Developmental Reasons for Visits: Providers were asked tolist their top 3 emotional/behavioral/developmental reasons for visits:

40/54 (59%) ADHD/oppositional behavior/conduct problems16/ 54 (30%) School difficulties – possible learning disability and developmental delay3/54 (5%) Enuresis/encopresis

3. Difficult to Treat: Providers were asked to list the most difficult problems to treat:

28/54 (52%) ADHD/ODD18/54 (33%) Encopresis18/54 (33%) Asthma

Texas Children’s Needs Assessment 2006

TCPA currently owns 47 practices in Houston serving 300,000 children

Pilot study to look at Primary Care PsychologyTop five mental health concerns at five offices

– ADHD related problems – differential dx– School problems and learning difficulties– Dx of depression– Developmental delay– Mental health follow up after referral

Why Address Behavior in Primary Care?

PCPs are the health professionals most likely to come in contact with children & adolescents with behavioral & emotional problems

Parents & children comfortable with PCP & office

PCP often knows family well, for long time

Why Address Behavior in Primary Care?

Non-stigmatizing service delivery

Scarcity of community mental health services

Promote mental health in children, adolescents, & families– Lack of services for children 0-6

Recognize early signs of psychosocial problems

When to Address Behavior in Primary Care?

Parent seeking information Relatively discrete behavior Mild to moderate severity Recent onset No major psychopathology Family situation reasonably stable Pediatricians routinely do this already.

What can Psychology meaningfully add to this?

How is it different from Healthy Steps?

Referred patients – Healthy Steps is a universal approach for all patients.– Healthy Steps excellent program for guidance,

screening Licensed mental health providers

– Can bill for services, self supporting– Can diagnose disorders in the 15% of children

who meet diagnostic criteria– Shared management of patients, not physician

run.– Can also assist with screening and other tools

for all patients, group parent information sessions etc.

Back to the Future

Collaborative practice first introduced by Schroeder (1975, 2004)

That practice involved:– Clinical Interventions– Teaching of Health Professions– Community Advocacy– Public Health Issues

Not all practices can meet all of these goals Each group needs to determine which of

these multiple roles Psychologists need to fill

What Does Primary Care Pediatric Psychology Look Like?

Understanding pediatric offices Differences between primary & tertiary care What does it look like at Nemours? First impressions: Missing the bus

Understanding Pediatric Offices

Majority of visits for infants & toddlers Each PCP may see up to 25-30 patients per

day Variety of visits: well-child, sick, problem Each PCP has own style & ways of interacting

with mental health

How is Primary Care Different from Tertiary Care?

Philosophy of practice– punctuality less important– see more patients but spend less time with each– sick visits

Need broad knowledge base – cannot specialize (“I don’t do that”)– development– behavior

Immediate access to Rx, some medical tests Flexibility is key!

Primary Care Pediatric Psychology: What Does it Look Like For Us?

4 sites 2-6 PCPs at each site Pediatric residency training at 3 sites Low income neighborhoods Racial and ethnic diversity Primarily Medicaid (90-95%)

– Single insurer simplifies insurance issues in the “carve out” era

Primary Care Pediatric Psychology: First Impressions

“We’ve been missing the bus!” Wider range of symptoms and

psychopathology– Subclinical/normative behavior– Severe psychopathology

Missed diagnoses and misdiagnoses– GAD referred as “sleep problem”– Several cases of PDD missed at well-child visits

Establishing a Primary Care Psychology Program: The Nemours Experience

Anecdotal evidence of PCP dissatisfaction with psychology services– Long wait lists– Infrequent communication from psychologists– Patients not following through with referrals to

tertiary care site Pediatric needs assessment Funding sources Setting up services

Setting Up Primary Care Psychology Services

Nemours Pediatrics: 8 sites in underserved areas

Grant applications to the Nemours Foundation and to HRSA– January to May 2002

Start services in fall 2002 Provide direct services on-site, consultation

and training Four sites in New Castle County, DE

Establishing a Primary Care Psychology Program: Training Considerations

Few, if any, psychology residents have worked in a primary care setting

Consider having resident shadow pediatricians

Must be comfortable with babies & small children

Primary care office is a smaller pond

Primary Care Training for Psychology Residents

Similar issues to hospital-based training Learn to identify self as medical professional Must be appropriately assertive and directive

with other medical professionals Develop understanding of pediatrician’s

knowledge base and skills in developmental & behavioral realm

Communicate information important to pediatricians clearly and with minimal jargon

Coordinated Care vs. Integrated Care

In Health Psychology discussion of these issues– Separate records or a joint record?– All providers treated equal

E.g. if a child comes to a pediatric appointment for a behavior problem do they go directly to Psychology (integrated) or see a Pediatrician (coordinated) first?

Impact of Electronic Medical Record (EMR)– Improved, instant communication– Confidentiality issues that go both ways– Families need to be informed that the record is shared

This is a continuum, not a dichotomy

Training Pediatricians: They Provide Most of the Front Line Mental Health

Services. AAP Guidelines

– Developmental Screening– Critical role for pediatricians is to counsel

parents– Child mental health as a top priority in 2005

Yet, pediatricians do not necessarily have the time or the training to assess and treat child mental health problems effectively and efficiently

Nemours Primary Care Behavior Program: Training Modules

Module I: Understanding Parent & Child Behavior

Module II: Assessment Modules III & IV: Selective Brief

Interventions in Primary Care

W. Douglas Tynan, Ph.D., ABPP, Deborah Miller, Ph.D., & Jennifer Shroff Pendley, Ph.D.

Assessment in Primary Care

– Use AAP materials– You ARE In pediatrics now– Intake Interview – DSM PC

Identify non-normative behavior Assess severity of problems Establish diagnosis

– Individualized Assessment ABC Analysis Facilitate treatment planning

– Motivational Interviewing: Identify factors that mediate or exacerbate problems

Overview of Nemours Primary Care Behavior Program

Course overview & objectives Teaching strategies

– Didactics– Hand-outs– modeling

Why address behavior in primary care?– Use of “Bright Futures Mental Health Materials

from the Academy of Pediatrics” Causes of behavior problems Basic behavioral strategies Brief, targeted interventions Motivational interviewing

Interventions for Behavioral Problems often Seen in Primary Care: Preschool

Tantrums & Oppositional Behavior– Example

Toileting Problems Sleep Problems Fighting / Aggression with Peers Feeding Problems

The Nemours Primary Care Psychology Program: Some Initial Outcome Data

Provider Satisfaction Survey Nemours Primary Care Psychology Program

Nemours Pediatric Provider Satisfaction Jan. 2004: Data to Guide Practice

Rating Scale 1 2Strongly Disagree

3 4 5 6 7Strongly Agree

Providers: N = 16, including 10 attendings, 3 residents, 3 Pediatric Nurse Practitioners atthe 4 sites

Behavior Issues in Primary Care Mean Score1. Parents frequently ask about behavior 6.22. I feel confident in advising parents about behavior 4.93. Management of behavior problems is difficult 4.9

Satisfaction with Psychology Services in Primary Care1. I am satisfied with the Psychology Services in my office 6.72. The Psychology Services here are appropriate and effective 6.83. My patients are satisfied with the Psychology Services 6.8

Interest in Other Services in Primary Care1. I would like Psychiatry Services 5.82. I would like Parent Education classes and groups 6.63. Social work, coordinating with other local services, wouldbe helpful for my patients

6.1

Pediatric Psychology Program: Outcome data

Calendar Year 2004 829 visits Calendar Year 2005 1072 visits Calendar Year 2006 871 visits Training Primary Care 2004 22 residents Training Primary Care 2005 27 residents

and 3 PNP interns

Texas Childrens Provider Satisfaction

6 practices divided into 3 options: As usual, Fast Track Referral, Psychologists on site

Increased satisfaction for both on site and Fast Track

Physician ratings of improvement much higher for on site.

Patients seen: 28% 0-5 year olds, 65% 6-12 year olds, 7% teens. Boys: Girls 2.5:1 This type of program appears to fit the needs of young children.

Results of Nemours Provider Satisfaction Survey

Content with Psychology Service Do not place a high priority on Psychiatry

services Want more parent education services Lack of confidence in own abilities to treat

behavioral problems.– Indicates need for more help in pediatric

training

Primary Care Program

>90% Medicaid insured 54% show rate for appointments in 2003 63% show rate for appointments in 2005

– Typical inner-city rates < 50% 68% show rate for 2006 How does this compare with existing

programs?

Resources

Treating children’s psychosocial problems in primary care. B.G. Wildman & T. Stancin (Eds.), Information Age Publishing, 2004

Consulting with pediatricians: Psychological perspectives. Drotar, D. Plenum Press, 1995.

Role of Mental Health Providers:Empirically Supported Therapy

Example, The Parent Child Conduct Clinic

Provide parenting skills therapy in Behavior Modification

Provide social skills training for children Emphasis on evidence based practice. Simply increasing service availability does

not have meaningful impact.

Coordinate Pediatric/School/Mental Health Services

Obtain informed consent for all parties to converse

Send copies of reports with your impressions.

Request that the school do evaluations for problems.

Give input to the team meetings Encourage parents to work with the school Engage an advocate if there are problems

www.picofdel.com

Treatment Approach IV:18 Great Ideas for Management

Parents are Shepherds, Not Engineers Reduce Delays, Externalize Time Externalize Important Information Externalize Motivation (Think win/win) Externalize Problem-Solving Use Immediate Feedback Increase Frequency of Consequences Increase Accountability to Others Use More Salient & Artificial Rewards

More of the Great Ideas (2)

Change Rewards Periodically Touch More, Talk Less Act, Don’t Yak Keep Your Sense of Humor Use Rewards Before Punishment Anticipate Problem Settings - Make A Plan Keep A Sense of Priorities Maintain a Disability Perspective Practice Forgiveness (Child, Self, Others)