Dr. Heidi McMillan wanted to offer integrated behavioral health care at Pediatric Partners of the Southwest about five years ago to help meet the needs of patients and to address the shortage of mental health care in the community.
“Families in crisis would bubble to the surface. Kids would end up in the ER, and kids would be failing school,” she said.
Often, the clinic would end up trying to help families pick up the pieces, but the clinic didn’t have a formal system to address or prevent these events, she said.
In the beginning, McMillan envisioned a program that would focus on a group of about 20 families, but she quickly realized that would not be enough. About 10 percent of children have a mental health need, and the practice has about 26,000 patient encounters in a year, she said.
Grant funding allowed the clinic to hire behavioral health providers about four years ago, and a second grant allowed it to offer appointments with specialists via a live video stream. Among those specialists is a psychiatrist who can see patients twice a month.
In recent months, the clinic started to introduce behavioral health care screenings for patients at key turning points in life and started to track those with highest risk of a crisis, such as risk of suicide, significant school failure or a hospitalization of another kind.
Pediatric Partners’ plan to improve behavioral health care was developed through a Johns Hopkins University program aimed at trauma prevention and treatment.
To help directly address youth suicide in the community, four months ago, the clinic started behavioral health screenings for patients about to start middle school.
“This is our biggest hope to contribute to suicide prevention,” McMillan said.
At these visits, a behavioral health provider will meet with patients and their parents, along with a doctor or physician’s assistant, to talk about adolescent developmental health issues and screen the patient for depression and substance use.
The special emphasis on mental wellness will be the focus of visits that happen at transition points in life – when a child turns 1 month old, 6 months, 18 months, before entering kindergarten, middle school, high school and college, she said.
Pediatric Partners’ focus on behavioral health is built on a large Kaiser Permanente study that found people who have experienced four or more adverse childhood experiences, such as physical abuse, sexual abuse, neglect and some forms of family dysfunction, are far more likely to die by suicide and experience chronic health problems, such as diabetes, heart disease and substance use.
Adverse childhood experiences can cause a fight-or-flight response in children, and that can cause constant production of cortisol, a stress hormone. High levels of cortisol can cause weight gain, increased blood pressure and it can change a child’s biology at the cellular level, McMillan said.
The American Academy of Pediatrics called on doctors in January 2012 to start screening children for these experiences.
Doctors and therapists at Pediatric Partners have spent the last year trying out different questionnaires to screen for traumatic experiences and other adversity.
The initial study on adverse childhood experiences focused on adults, and it asked them to reflect on their experiences as children. A clinic in San Francisco adapted that questionnaire for children and had some success with it.
However, at Pediatric Partners, health providers found the questions were not appropriate for those families experiencing trauma. Some would say they did not have any adverse childhood experiences or they became upset because they were not ready to address them.
“Most practices have not figured out the right way to do it because it’s so hard to screen families in a sensitive, supportive way. That’s why it’s taken us a year to do this,” McMillan said.
So the clinic shifted to a screening with 14 questions developed at Children’s Hospital Colorado that allow health care providers to ease parents into the topics involving trauma, and it has worked well, she said. The questionnaire draws on social determinants of health, such as housing status, food security, transportation and health insurance.
Each question allows clinic staff to recommend a resource to help meet the need in question. For example, they will write a “prescription” for food.
About six months ago, the staff launched behavioral health screenings for 1-month-old children, because a new baby can add financial and emotional stress. But parents also tend to be excited.
“They are primed to be the best parents they can be,” McMillan said.
The screenings will also be done when children turn 6 months old, 18 months and before kindergarten.
At appointments with 1-month-old children, both a primary health provider and therapist meet with family members to explain how they can build resiliency in children that will allow them to overcome adverse childhood experiences.
“The single most important resiliency factor is a caring adult who is consistent in a child’s life; that may be a parent, that may be a grandparent. Often, it’s a coach, so sports are really important,” she said.
The clinic staff illustrate the relationship between adverse experiences and resiliency with a beach ball filled with air.
“Every experience your child has that’s resiliency-building, whether it’s a dance performance, a soccer game, you know, time with a loving parent or grandparent or teacher, puts air into this beach ball,” McMillan said.
When adversity comes along, the resiliency will allow them to bounce back, she said.
The practice also screens new mothers for depression for the first year after a baby is born because a new mother’s depression is strongly linked to developmental delays, she said.
The clinic plans to start screening children for social determinants of health, such as housing status and economic stability, before kindergarten, and with parents’ permission, staff plan to be in contact with teachers and counselors at elementary schools so the staff can understand a student’s home situation.
“If a child is undergoing trauma, not dramatic trauma, but just ACEs (adverse childhood experiences), just enough that their fight or flight system is active, the thing that shuts off is cognitive function, so they can’t focus,” McMillan said.
During the new appointments for middle school students, staff do not screen for social determinants of health; they talk about what patients can expect in middle school and screen them for depression and substance use.
The staff will also explain the effects of social media. Facebook and other online platforms can be addictive because notifications trigger a release of dopamine in the brain. However, screen time doesn’t build resiliency, and it can make users more detached. It can also lead to negative social experiences.
“Certainly, kids are very affected by bullying online; they are very affected by comparing themselves with that imaginary ideal that’s promoted online. We know this by speaking with hundreds of kids,” McMillan said.
The staff also recommend apps for anxiety and other methods to deal with stress. They may directly address suicidality and what to do if a friend is suicidal, if appropriate.
“It’s going to be hard to measure outcomes as far as ‘is this preventing suicidal thoughts or actions in the middle school population?’ But beginning the conversation in a way that normalizes these conversations at a well-child visit, I think, is a good approach,” she said.
Behavioral health providers will also attend checkups with incoming high school freshmen who will be screened for their adverse childhood experiences. At that appointment, the behavioral health focus will be on their future plans.
“Kids are less likely to be suicidal or depressed if they are engaged and have goals,” McMillan said.
To better serve families and children who are in a crisis of some kind, whether it be suicidality or a different kind of hospitalization, the clinic started tracking each family based on their risk level seven months ago.
The risk levels are determined by mental health needs, how well the family is functioning and their social determinants of health.
“It’s intended entirely to support families, and it’s entirely confidential,” she said.
Those patients with highest level of risk are often the patients with most adverse childhood experiences.
The practice has found it has more than 100 patients in crisis or “knocking on the door” of a crisis, McMillian said. Families in these top two categories are considered to be in the practice’s “child wellness home.”
Assigning levels of risk to families allows for good communication across departments in the medical practice.
“This allows us to communicate in the office so that each department will look through the lens of potential stress or trauma in others’ lives and provide compassionate support,” she said.
For example, if a family at the highest level of risk is late, the front desk will know to call, she said.
Those at the highest risk level will have a behavioral health provider and a care coordinator attend all of their appointments, McMillan said. If they can’t make it to their appointment, they will have the option of speaking to a provider via a video-chat on their cellphone.
Over time, the practice hopes to see patients’ risk levels decline through treatment and as the staff refers families to nonprofits that meet their needs outside of health care.
Other primary care clinics, such as Mercy Family Medicine and Pediatric Associates of Durango, have also hired behavioral health professionals to see patients.
Much of Pediatric Partners’ integrated behavioral care is grant-funded, and it is unclear exactly how it will be maintained. However, McMillan said the practice is committed to having at least one full-time behavioral health therapist on staff.
