Handbook of Pediatric Psychological Screening and Assessment in Primary Care

Mark E. Maruish

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781138723146
• eBook ISBN:
  9781351757348
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Handbook of Pediatric Psychological Screening and Assessment in Primary Care provides an overview of the principles of screening, monitoring, and measuring of the treatment outcomes of behavioral health disorders in pediatric primary care. The Handbook serves as a guide to the selection of psychometric measures that can be used to screen for and/or assess behavioral health problems of children and adolescents. The Handbook is an invaluable reference to behavioral health clinicans in maximizing potential benefits in efficient assessment and effective treatment of children and adolescents in pediatric primary care settings as well as other health care settings.

Part I
General Considerations

1
Introduction

Mark E. Maruish

The historically inefficient, costly, and unsustainable system of health care in the United States is going through dramatic changes. Spurred by the passage of the Patient Protection and Affordable Care Act (ACA, 2010) and focused on the linked goals of the Triple Aim—improved population health, improved quality or experience of health care by the individual patient, and reduction in health care costs (Berwick, Nolan, & Whittington, 2008; Laderman, 2015; Lewis, 2015; McDaniel & deGruy, 2014; Peek, Cohen, & deGruy, 2014)—efforts are underway to transform the nation’s health care delivery system into one that is more efficient, effective, and cost-effective. Recently, some have recommended that the Triple Aim be expanded to become the Quadruple Aim to include improved work life of health care clinicians and staff as a goal in optimizing health system performance (Bodenheimer & Sinsky, 2014).

One way that this transformation is being achieved is through a shift in the view of and the approach to health and disease from a biomedical model, which addresses mental disorders only if they can be explained biologically, to a biopsychosocial model (Engel, 1977), which also takes into account psychological and social factors and their interactions. This shift can be seen in the delivery of health care in primary care settings, and it may be viewed as one impetus for the ongoing movement toward more collaboration among medical and behavioral health care providers and varying degrees of the integration of physical and behavioral health care. Although integration can be seen in several types of medical specialty care settings such as obstetrics/gynecology (Poleshuck & Woods, 2014) and oncology (Kazak & Noll, 2015), its appearance and impact are perhaps most visible in primary care settings, including those that specifically provide services to child and adolescent patients.

Accompanying the trend to integrate behavioral health care services in pediatric primary and specialty care settings are opportunities for clinical, pediatric, child clinical, and other psychologists providing services in or to those settings to capitalize on their clinical, research, and educational training and skills to contribute to the improvement in health care during this time of transformation. Among the clinical skills that can have the most impact on pediatric primary care patients are the psychologist’s testing and assessment skills. The psychologist’s training and expertise in psychological testing based assessment distinguishes them from other behavioral health care professions more than anything else. For this reason, the further development of psychological testing and assessment skills as they can be utilized in and contribute to the delivery of quality, effective health care in pediatric primary care settings is the focus of this book.

The purpose of this chapter is to provide the reader with an overview of the impetus for, current interest in, and efforts toward the integration of behavioral health care in primary medical care settings, with particular emphasis on the role that psychological screening and assessment can play in integrated physical and mental health care programs. The intent is not to present a comprehensive exposition of endeavors in this area; rather, it is hoped that the information contained herein will provide a context that facilitates an understanding of the detailed information presented in the chapters that follow.

As a point of clarification, when used in this chapter, primary care will be defined using the definition provided by the Institute of Medicine (1994), that is, as:

the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

(p. 15)

Pediatric primary care (PPC) will refer to primary care that is provided by pediatricians or other medical professionals (e.g., family practitioners, nurse practitioners, physician’s assistants) trained in the delivery of health care services to children and adolescents in specialized or general practices. Unless otherwise specified, the term psychologist will include pediatric psychologists, child clinical psychologists, and any other types of psychologists (e.g., clinical psychologists, health psychologists, school psychologists) who provide clinical or consultative services in or to pediatric primary care settings.

Health Care Costs

The cost of health care in the United States is staggering. And as will be shown, there are indications that these costs—for health care in general and behavioral health care specifically—will continue to rise in the foreseeable future.

Overall Health Care Costs

Based on Centers for Medicare and Medicaid Services (CMS) data reported by Martin, Hartman, Behson, Catlin, and the National Health Expenditure Accounts Team (2016), national health expenditure was $2.80 trillion, or 17.3% of the GDP in 2012; $2.88 trillion, or 17.3% of the GDP in 2013; and $3.03 trillion, or 17.5% of the GDP in 2014. Spending increased 3.8%, 2.9%, and 5.3% in those same three years, respectively. Per-capita expenditure for each of the three years was $8,927, $9,115, and $9,523, respectively, representing a per capita growth increases of 3.0%, 2.1%, and 4.5%, respectively, over the previous year. Martin et al. also reported that for 2014, Medicare spending was $618.7 billion, Medicaid spending $495.8 billion, and private health insurance spending was $991.0 billion.

By 2020, health care costs are expected to rise to $4.7 trillion, a figure that will represent 19.8% of the GDP (Nordal, 2012). This increase can in part be attributed to projected growth in Medicare enrollees and the expanded health care coverage mandated by the ACA. Also, Keehan et al. (2017) reported projected average health spending to grow an average of 5.8% from 2015 to 2025 annually and to represent 20.1% of the total U.S. economy by 2025.

Behavioral Health Care Costs

The cost of mental health and substance use disorders has shown a steady increase over the past three decades. The Substance Abuse and Mental Health Services Administration (SAMHSA; 2016) revealed that mental health and addiction treatment spending increased from $32.4 billion and $9.1 billion, respectively, in 1986 to $186.1 billion and $33.9 billion, respectively, in 2014. The projected costs for mental and substance use disorders in the future present a somewhat more positive picture than those for general health care. Of the total mental health costs, 35% was attributed to outpatient services, 27% to retail prescription drugs, 16% to inpatient services, 12% to residential services, and 9% to insurance administration. For addiction treatment services, the percentage breakdown was 40%, 5%, 19%, 27%, and 8%, respectively. In addition, the U.S. Department of Health and Human Services (HHS, 2016) reported that the economic impact of alcohol misuse and illicit drug use to be $249 billion and $193 billion, respectively. Moreover, SAMHSA (2014) projected direct spending costs for behavioral disorder treatment (excluding comorbid health costs and indirect costs for things such as lost productivity and wages) to rise to $280.5 billion in 2020. This estimate includes the costs resulting from the implementation of the ACA and compares to reported behavioral health treatment costs of $171.7 billion in 2009.

Perhaps as important as cost considerations is the realization of the patient-care and financial benefits that can accrue from the integration of primary medical and behavioral health care. This has resulted not only in professional- and academic-level discussions and investigations but also in the implementation of an increasing number of integrated programs in primary care settings (e.g., see Hunter, Goodie, Oordt, & Dobmeyer, 2017; Kolbasovsky, Reich, Romano, & Jaramillo, 2005). More specifically, numerous pediatric primary care programs designed to capitalize on the benefits of integrated medical and behavioral care are in place (e.g., see American Academy of Pediatrics [AAP], 2009; Borschuk, Jones, Parker, & Crewe, 2015; Etherage, 2005; London, Watson, & Berger, 2013; Ward-Zimmerman & Cannata, 2012). Currently, the degree to which integrated service delivery is present in participating practices varies as a function of a number of factors, such as available funding, third-party reimbursement criteria, staff interest and commitment to the program, availability of resources, and office space limitations. Regardless of the extent to which these services are merged, efforts toward attaining this goal attest to the belief that any steps toward integrating behavioral health care services in both adult and pediatric primary care settings represent an improvement over the more traditional model of segregated service delivery.

Prevalence of Child and Adolescent Behavioral Health Disorders

Mental health and substance abuse disorders, that is, behavioral health disorders, have a significant presence in the U.S. in both the adult and pediatric populations. The demands of those suffering from these disorders can have a substantial impact on health care resources—both behavioral and medical—and thus merit the attention of those who are charged with their care as well as those attempting to control the associated costs.

Prevalence in the U.S. General Population

The commonly cited estimate in the literature is that approximately 20% of the U.S. child and adolescent population have a mental/psychiatric/psychosocial/behavioral/emotional disorder (e.g., see Cederna-Meko, Ellens, Burrell, Perry, & Rafiq, 2016; Costello, Copeland, & Angold, 2011; Dempster, Wildman, & Duby, 2015; Pidano, Kimmelblatt, & Neace, 2011; Simonian, 2006). However, several authors have cited various large prevalence estimate ranges, such as 12% to 27% (Simonian, 2006).

Disorder-specific prevalence estimates for the U.S. general population child and adolescent samples derived from earlier surveys, surveillance systems, and studies are also available. Some of these data are presented in Table 1.1. One will note that some of the reported prevalence estimates for a given disorder vary considerably from study to study. Differences in samples, the time at which the survey was conducted, the diagnostic criteria employed, and other factors likely play into the variations in findings. Regardless, the data indicate that mental and substance use disorders present a significant problem in the U.S. child and adolescent populations. Interested readers are referred to other sources reporting child and adolescent mental disorder prevalence data (for example, see Bronsard et al., 2016; Costello et al., 2011; Ginsburg & Foster, 2009; Merikangas, Nakamura, & Kessler, 2009; Murphey, Barry, & Vaughn, 2013; Weitzman et al., 2015; Younger, 2017).

Table 1.1 A Sample of Estimated Prevalences in the U. S. General Pediatric Population for Common Behavioral Health Disorders and Conditions

The Center for Behavioral Health Statistics and Quality (CBHSQ, 2016a) recently reported what might be the most current estimates of the prevalence of substance abuse and associated dependencies and disorders. These data come from SAMHSA’s 2015 National Survey on Drug Use and Health (NSDUH) that was administered to 68,073 individuals ages 12 or older, of which 16,911 were aged 12 to 17. Data were analyzed, and prevalence estimates for alcohol and substance use behaviors and related factors were derived separately for those adolescents aged 12 to 17 years. The NSDUH did report specific data related to adolescent substance use, the most relevant of which are reported in Table 1.2.

Results from the NSDUH indicated that 8.8% of adolescents reported the use of illicit drugs (marijuana/hashish, cocaine, inhalants, hallucinogens, heroin, and nonmedical use of prescription-type drugs) during the past month and 17.5% during the past year (CBHSQ, 2016a). Heavy alcohol use (five or more drinks on the same occasion on 5 or more days during the past 30 days) was reported for 0.9% of adolescents. Based on the American Psychiatric Association’s dependence and abuse past-year criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000), 5.0% of adolescents met the criteria for substance use (illicit drugs or alcohol) disorders in the past year, while 2.4% met the criteria for substance dependence. Upon inspection of Table 1.2, one also will note that with few exceptions, the percentage of adolescents reporting a particular type and/

Table 1.2 Selected Combined and Individual Age Group Adolescent Substance Use Findings from the 2015 National Survey on Drug Use and Health Presented as a Percentage of Age-Group Respondents

or frequency of substance use increases for each age group from 12 years to 17 years. Interested readers are referred to other sources reporting child and adolescent alcohol and substance use prevalence data (e.g., see Foy, 2010).

Although mental health issues were not the primary focus of the survey, the reported 2015 NSDUH results revealed that 12.5% of...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of Figures
• List of Tables
• Preface
• Contributors
• PART I General Considerations
• PART II Psychological Assessment Instruments and Procedures
• PART III Examples of Integrated Pediatric Primary Care Programs
• Author Index
• Subject Index