Primary Care Pediatric Psychology
W. Douglas Tynan, Ph.D., ABPP
For copies please email:[email protected]
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)