Primary Care Pediatric Psychology

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Primary Care Pediatric Psychology

• W. Douglas Tynan, Ph.D., ABPP
• For copies please email
• Dtynan_at_nemours.org

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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

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Unmet Needs for Parent Support Guidance in
Pediatric Care
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Nemours Pediatric Needs Assessment
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Texas Childrens Needs Assessment 2006

• TCPA currently owns 47 practices in Houston
  serving 300,000 children
• Pilot study to look at Primary Care Psychology
• Top 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

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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

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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

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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?

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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.

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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

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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

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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

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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
  dont do that)
• development
• behavior
• Immediate access to Rx, some medical tests
• Flexibility is key!

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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

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Primary Care Pediatric Psychology First
Impressions

• Weve 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

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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

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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

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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

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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 pediatricians
  knowledge base and skills in developmental
  behavioral realm
• Communicate information important to
  pediatricians clearly and with minimal jargon

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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

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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

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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.

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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

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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

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Interventions for Behavioral Problems often Seen
in Primary Care Preschool

• Tantrums Oppositional Behavior
• Example
• Toileting Problems
• Sleep Problems
• Fighting / Aggression with Peers
• Feeding Problems

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The Nemours Primary Care Psychology Program Some
Initial Outcome Data

• Provider Satisfaction Survey
• Nemours Primary Care Psychology Program

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Nemours Pediatric Provider Satisfaction Jan.
2004 Data to Guide Practice
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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

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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 2.51 This type of
  program appears to fit the needs of young
  children.

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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

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Primary Care Program

• gt90 Medicaid insured
• 54 show rate for appointments in 2003
• 63 show rate for appointments in 2005
• Typical inner-city rates lt 50
• 68 show rate for 2006
• How does this compare with existing programs?

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Resources

• Treating childrens 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.

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Role of Mental Health ProvidersEmpirically
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.

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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

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Treatment Approach IV18 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

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More of the Great Ideas (2)

• Change Rewards Periodically
• Touch More, Talk Less
• Act, Dont 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)

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