Addressing the Mental Health Needs of DC’s Children CHILDREN’S MENTAL HEALTH IS A GROWING public health issue, as roughly 15% of children in the U.S. experience a mental disorder each year (CDC, 2013) and half of all adults with a mental health disorder had symptoms by the age of 14 (Kessler, 2005). Factors affecting children’s mental health start in infancy and young childhood, during the early beginnings of brain and self-regulation development, and continue throughout childhood and adolescence (Bayer, 2011). Recognizing the different risk factors and signs of a mental health issue at each development stage is the first step in combatting these often chronic conditions. While many of these issues can be identified early, few children receive the subsequent services that they require (McCue Horwitz, 2012). DC’s children are particularly underserved, especially those enrolled in Medicaid, as at least half of those children don’t receive the treatment their mental health diagnosis requires (DC Action for Children, 2012). Identifying Risk Factors Risk factors for children’s mental health apply to children of all ages, including infancy (Bolten, 2013). Identifying and mitigating these risks is a critical component of prevention. Some risk factors that apply to children of all ages include the child’s poor physical health; younger and less educated mothers; negative family dynamics, and demographics (i.e. low socioeconomic status) and community context (i.e. lack of accessible resources). While some children may only have one or two risk factors, many will have several. It is important to note that the cumulative risk effect is more important in determining psychological problems than one single stressor, no matter its magnitude (Halpern, 2004). Mental Health and Children with Special Health Care Needs (CSHCN) Studies suggest that children with special health care needs (CSHCN) have a greater incidence of emotional, behavioral, and social adjustment problems (EBDP) than children without chronic conditions, often due to disease-related stress, frustration with medical management, social isolation from peers, and despair at the awareness of limitations or differences from others (Tang, 2008). Additionally, urban community stressors, such as poverty and crime; race; and the child’s health status are also significantly correlated with mental health problems among CSHCN (VanLandeghem, 2009). In fact, 25% of parents of CSHCN report that their child has a mental health need that is attributed to their condition. In particular, mental health needs are more frequent in CSHCN that have EBDP, as 67% of parents of children with EBDP reported a mental health concern (Inkelas, 2007). Additionally, children with only Medicaid managed care are 1.8 times more likely to have an unmet mental health needs (Tang, 2008). It is also important to recognize that parents of CSHCN may have mental health needs of their own due to the stresses of navigating the medical field and providing more extensive care than required by children generally. What Can I do to Address the Mental Health Needs of Children for Whom I Provide Services? If you are a primary care provider: Primary care offers an underutilized potential for identifying and treating children’s mental health needs (Asarnow, 2002). Compared with adults, children with mental health concerns are often brought by their parents to their primary care provider (PCP) rather than This project was funded by the Government of the District of Columbia, Department of Health, Community Health Administration Grant No. CHA.CPPW.GU.062012 Government of the Disctict of Columbia Vincent C. Gray, Mayor DC RESOURCE CENTER FACT SHEET: ADDRESSING THE MENTAL HEALTH NEEDS OF DC’S CHILDREN to a psychiatric specialist (Olfson, 2014). Fifteen to 20% of children and adolescents seen in primary care have a behavioral health disorder, yet only one in five children are identified by their pediatricians and even fewer receive mental health services (Cassidy, 1998). PCPs can efficiently and appropriately help these children by applying chronic care principles, similar to those employed for treating asthma or diabetes, to children with mental health needs. The American Academy of Pediatrics (AAP) endorses the chronic care model, which includes supporting child and family self-management, defining the roles of the practice, providing support tools for the family, and strengthening the clinical referral systems (Foy, 2010). In DC, the Department of Health and the Administration on Community Health (the state Title V agency) has funded the DC Collaborative for Mental Health in Pediatric Primary Care, an organization including providers, researchers, and respresentatives from key agencies, local academic universities and medical centers, community advocacy organizations, and the state chapter of the AAP. The DC Collaborative aims to improve integration of mental health in pediatric primary care through assessment of community needs and capacities, planning, and policy development. Additionally, the DC Department of Health Care Finance (DHCF) indicates that Medicaid Managed Care Organizations (MCO) as part of the EPSDT requirements are required to ensure annual mental health screenings of children and youth by their Primary Care Provider (PCP). How Can I Screen for Mental and Behavioral Health Issues? Standardized screening tools are useful to PCPs. In fact, studies indicate that the use of formal tools is superior to subjective surveillance in detecting behavioral health problems in primary care (Simonian, 2001). There are many screening tools available, however tools should be developmentally appropriate and clinically useful; brief; easy to administer, score, and analyze; and should have acceptable reliability and validity (Carter, 2010). While screening tools are emphasized in practice, it is important •2• for PCPs to recognize that screening may lead to overidentification, therefore clinical judgment, additional screenings, and further triage will be necessary for an accurate diagnosis (Asarnow, 2002). It is also important to screen for physical or environmental conditions that could affect development (DC Health Check, Validated Screening Tools for Middle Childhood, n.d.): • Lead hazards (older homes, recently renovated older homes, lead-based paint, lead dust, pica, drinking water, certain ceramic ware); • Anemia risks (low iron intake, history of irondeficiency anemia, restrictive or inadequate diet); and • Signs of neglect, physical or sexual abuse, malnutrition, and deprivation Cultural Competency in Screening Almost all developmental tests have at least some element of cultural bias. It is important for testers to be cognizant this fact and be sensitive and well-informed about families with different cultures or practices. Those administering screening tools should be knowledgeable about the family’s culture and the language of the child, be respectful of the family’s cultural values, and ensure that all tests and evaluation materials are given in the native language of the child (DC Health Check, Validated Screening Tools for Infancy, n.d.) There are varying degrees of stigma related to mental and behavioral health problems across cultures. Understanding these concerns is vital to helping families take steps to address problems that may be identified in the screening process. An excellent resource on cultural competence in screening is available at http://www.maactearly.org/uploads/9/2/2/3/ 9223642/4_considering_culture_asd_screening.pdf. While it focuses on screening for autism, the principles apply to any type of mental health, behavioral or developmental screening. Are screening tools effective?—Myths About Screening Tools (CDC, 2014) MYTH 1. There are no adequate screening tools for preschoolers. Although this may have been true decades DC RESOURCE CENTER FACT SHEET: ADDRESSING THE MENTAL HEALTH NEEDS OF DC’S CHILDREN ago, today most screening tools have sensitivity and specificities greater than 70%. Myth 2. A great deal of training is needed to administer screening correctly. Training requirements are not extensive for most screening tools, and many can be administered by paraprofessionals. Myth 3. Screening takes a lot of time. Many screening instruments take less than 15 minutes to administer, and some require only about 2 minutes of professional time. Myth 4. Tools that incorporate information from the parents are not valid. Parents’ concerns are generally valid and are predictive of developmental delays. Research shows parental concerns detect 70-80% of children with disabilities. What Screening Tools Should I Use? DC Health Check Training and Resource Center provides information about validated screening tools with links to the tools. INFANCY http://www.dchealthcheck.net/trainings/issues/ mental_health/mental_health_infancy3.html EARLY CHILDHOOD http://www.dchealthcheck.net/trainings/issues/ mental_health/mental_health_earlychildhood3.html MIDDLE CHILDHOOD http://www.dchealthcheck.net/trainings/issues/ mental_health/mental_health_middlechildhood3.html ADOLESCENCE http://www.dchealthcheck.net/trainings/issues/ mental_health/mental_health_adolescence3.html After Identifying a Problem in Screening—What Next? Many common behavioral problems can be effectively addressed within the primary care setting. Bright Futures in Practice: Mental Health Volume I •3• http://www.brightfutures.org/mentalhealth/pdf/index.html contains a section called Bridges with practical and effective interventions within the primary care setting for common mental health and behavioral issues. However effective referral for additional evaluation and treatment is also essential. The DC Collaborative for Mental Health in Pediatric Primary Care has created the Child and Adolescent Resource Guide http://www.dchealthcheck.net/resources/healthcheck/ mental-health-guide.html which will be updated with new information. The guide provides information about services by type and by age/stage of the child. It also provides additional resources for primary care providers about addressing the mental and behavioral health needs of the children they serve. What if I am Not a Primary Care Provider? Others who provide service to children and their families can play an important role in supporting children’s mental and behavioral health. Learn about typical child mental and behavioral development and how to recognize risk factors and potential problems. An excellent resource for this is Bright Futures in Practice: Mental Health that presents information about childhood mental health within a developmental context and offers a tool kit for professionals and families for use in screening, care management, and health education available in PDF format at http://www.brightfutures.org/mentalhealth. Raise concerns with families and seek their perspective on their child’s development, even if you are addressing other needs in your service provision. Encourage families to share their concerns with their child’s primary care provider and to ask for mental and behavioral health screening within their medical homes. If you are working with a child who is receiving services in DC’s Child and Family Service Agency ask if there has been a mental health screening completed. Learn about mental and behavioral resources within the community and support families in seeking those services. 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