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We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an
unapproved/investigative use of a commercial product/device in this presentation.
Preventive Services Improvement Project
Implementing Bright Futures For Early Childhood:
Partnering with Parents & the CommunityMarian Earls, MD
Paula Duncan, MD
Preventive Services Improvement Project Learning Session
January 21-22, 2011
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West Reading, PAAll About Children
Pediatric Partners PC
Boston, MAChildren’s Hospital Primary Care Center
St Louis, MODanis Pediatrics
Ft Washakie, WYWind River Service Unit
Southern Pines, NCSandhills Peds
Brooklyn, NYLutheran Family
Health Ctr
Hurst, TXCook Children’s
Physician Network
San Antonio, TXCommunity Medicine
Associates
Warrington, PAKressly Pediatrics
Lorton, VAAll Pediatrics
Iowa City, IAU of Iowa
Dept of Peds
Charlotte, NCCMC Myers
Park Pediatrics
Redwood City, CAFair Oaks
Children’s Clinic
Merritt Island, FLAtlantic Coast Pediatrics
Hays, KSHays Med
Pediatric Ctr
Philadelphia, PARoxborough Peds
Williston, NDComprehensivePediatric Care
Haverstraw, NYHaverstraw Peds
Tucson, AZSan Xavier Clinic
Milwaukee, WI16th Street CHC
Appleton, WIChildren’s Health Ctr@ St Elizabeth Hosp
Thanks to our 21 PreSIP Teams!
What We Know
Impact of experience on brain development.
Growth, development, and behavior are inextricably linked.
Emotional development occurs in the context of a relationship (bonding, attachment, reading cues).
Role of Experiencein Early Brain Development
Activation of genes and gene productsInteraction with genetics to determine
morphological and functional brain organization
Requirement for brain development to be normal
Critical and sensitive periods
•Physiological responses to stress in the infant’s environment affect the infant’s social-emotional development.
•The activation of the physiologic stress response system results in increased levels of stress hormones.
•Persistent elevation of cortisol, can disrupt the developing brain’s architecture in the areas of the amygdala, hippocampus, and prefrontal cortex (PFC), and therefore ultimately can impact learning, memory, and behavioral and emotional adaptation.
Toxic Stress
Prevalence and Risk
About 16% of children have disabilities including speech
and language delays, mental retardation, learningdisabilities and emotional/behavioral problems.
____________
(Only 30% are detected prior to school entrance.)____________________
Prevalence and Risk
13% of preschool children have mental health problems.
This rate increases with the co-occurrence of other risk factors:
PovertyMaternal depressionSubstance abuseDomestic ViolenceFoster care
Poverty
Severe child hunger associated with:Increased rates of internalizing behavior
problems in preschoolers and school-age children.
Increased rates of anxiety and depression at school age.
(U Mass Med study 2002)
Foster Care
Children of “risky families,” who have characteristics of conflict, aggression, relationships that are neglectful.
“Risky” environment disruptive of biological stress-response regulatory systems, and to psychosocial functioning.
Impact of Maternal Depression
Infants are at risk for insecure attachment. Children with insecure attachment are more likely to have behavior problems and conduct disorder.
Maternal depression in infancy is predictive of cortisol levels in preschoolers, which is linked with anxiety, social wariness and withdrawal
When mothers experienced major depression, then attachment disorders, behavior problems, and depression and other mood disorders can occur in childhood and adolescence
Disparities
Minorities receive about ½ as much outpatient mental health care as whites.
Most children who need a mental health evaluation do not receive services, and Latinos and uninsured children have especially high rates of unmet needs.
Limited access to mental health services for parents (often underinsured/uninsured)
Disparities
Children in living in poverty have twice the rate of mental health problems as the general population of children.
Rates of use of mental health services are extremely low among preschool children.
Disparities
System CapacityWorkforce shortage of child and adolescent
psychiatrists and clinicians who can work with children.
Even greater workforce shortage of child psychiatrists and psychologists who can work with very young children.
Shortage of mental health providers who can treat the mother-infant dyad
National Perspectives onHealthy Development in Young Children
AAP: new Bright Futures guidelines
AAP: new priority in strategic plan-early brain development
AAP: Task Force on Mental Health & COPACFH
AACAP: Collaborative Mental Health Care Partnerships in Pediatric Primary Care
ABCD (Assuring Better Child Health & Development) Projects: early childhood social-emotional development and mental health
Bright Futures, the AAP, and Health Reform
Coverage of Preventive Services under section 2713 of ACA, July 19, 2010
All private health plans must cover, without cost-sharing all services described in Bright Futures: Guidelines for Health Supervision of Infants Children and Adolescents, 3rd Edition, as of Sept 23, 2010.
Issues: grandfathered plans, language does not include Medicaid plans.
AAP is directly advocating with Secretary Sibelius on these issues.
AAP: Task Force on Mental Health & Committee on the Psychosocial Aspects of Child & Family Health
Chapter Action Toolkit, 2008The Future of Pediatrics: Mental Health
Competencies for Pediatric Primary Care, PEDIATRICS, 124(1), July 2009.
Supplement to Pediatrics (June, 2010)Addressing Mental Health Concerns in Primary
Care: A Clinicians Toolkit (July, 2010)Incorporating Perinatal and Postpartum
Depression Recognition and Management into Pediatric Practice (November 2010)
Addressing Social Emotional Morbidity (pending)
AAP Defines Medical Home
AccessibleFamily-CenteredContinuousComprehensive CoordinatedCompassionateCulturally competent
Medical Home also means…
Caring for the whole child
Considering physical, developmental and mental health together
“not separating the head from the body”
Bright Futures
Health Promotion Themes include: Promoting Family Support Promoting Child Development Promoting Mental Health Promoting Healthy Weight Promoting Healthy Nutrition Promoting Physical Activity Promoting Oral Health Promoting Healthy Sexual Development & Sexuality Promoting Safety & Injury Prevention Promoting Community Relationships & Resources
Bright Futures
1994 1996 1998 2000 2001 2002 2003+
Pfizer Partnership
BF in Practice
Oral Health
BF Pocket Guide
Encounter Forms for Health
Professionals and Families
Anticipatory Guidance
Cards
BF II
BF II Pocket Guide
Encounter Forms for Families II
BF in Practice Nutritio
n
Family Tip
Sheets
BF in Practic
e
Physical
Activity
BF in Practic
e Mental Health
& Toolkit
1990: Initiated by MCHB & Medicaid
NCEMCH 1995: Building Bright Futures AAP
Evaluation&
State Case
Studies
Guidelines
Bright Futures Implementation
2004 2007 2008 2009 2010
BF Periodic Survey #56
BF Pocket Guide
BF
EQIPP Module
BF Perform
Prev. Serv
BFTIBF
NutritionBF
Activity Book
2011 2012
BF
National Fam. Org
Mtg
BF
VDH Web Site
ACA
BF
PreSIP
State of WI
Brightening Oral Health Healthy
Active Living for Families
2000 & 2002
…is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.
We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an
unapproved/investigative use of a commercial product/device in this presentation.
Example: Example: 18 month 18 month
oldold
We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an
unapproved/investigative use of a commercial product/device in this presentation.
Context
The 18-month-old requires gentle transitions, patience, consistent limits, and respect. One minute he insists on independence; the next minute he is clinging fearfully to his parent.
We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an
unapproved/investigative use of a commercial product/device in this presentation.
Who has an 18 month old?
ANTICIPATORY GUIDANCEEncourage your toddler’s language development by reading and singing to her, and by talking about what you both are seeing and doing together.
Books do not have to be “read.” Talk about the pictures or use simple words to describe what is happening in the book.
Do not be surprised if she wants to hear the same book over and over.
Use simple, clear phrases to give your child instructions.
SAMPLE QUESTIONSHow does your child communicate what she wants? Who or what does she call by name? What gestures does she use to communicate effectively? For example, does she point to something she wants and then watch to see if you see what she’s doing? Does she wave “bye-bye”?
The development of language and communication during the early childhood years is of central importance to the child’s later growth in social, cognitive, and academic domains. Communication is built upon interaction and relationships. Health care professionals have the opportunity to educate parents about the importance of language stimulation, including singing songs, reading, and talking to their child.
Parents may ask health care professionals about the effects of being raised in a bilingual home. They may be reassured that this situation permits the child to learn both languages simultaneously.
LANGUAGE PROMOTION/HEARINGEncouragement of language, use of simple words and phrases, engagement in reading/singing/talking
Bright Futures is the health promotion/disease prevention part of
the medical home
At the heart of the medical home is the relationship
between the clinician and the family or youth
Opportunities for Prevention and Promotion in Primary Care
Prenatal VisitsPsychosocial and maternal depression
screeningDevelopmental & behavioral screening and
surveillance in pediatric and family practice offices
Social/emotional screening for children identified “at risk”
Implementation requires a QI approach to office
process
Mental Health Competencies
The “primary care advantage”Longitudinal, trusting relationshipFamily centerednessUnique opportunities for prevention &
anticipatory guidanceUnderstanding of common social-emotional &
learning issues in context of developmentExperience in coordinating with specialists in the
care of CSHCNFamiliarity with chronic care principles & practice
improvement
Talking with Families
Identify child and parent’s strengths Discuss developmental issues Discuss transition stages Share Information Discuss community resources
PreSIP: Implementing Bright Futures in Early Childhood
Maternal Depression ScreeningBMI Oral HealthDevelopmental ScreeningAutism ScreeningEliciting parent concerns and strengthsCommon factors approachAnticipatory Guidance
PreSIP: Practice Systems
Office Systems InventoryPreventive Services Prompting SystemRisk StratificationFamily InvolvementPromoting Family’s Experience of CareCommunity Linkages