Implementing Perinatal Depression Screening into the WCC

Problem: Texas enacted House Bill 2466, effective September 1, 2017, to provide Medicaid and child health plan coverage for maternal depression screening during an office visit for the child.  The purpose of this brief report is to inform clinicians of this coverage and urge Pediatricians to standardize the practice of perinatal screening during well child checks in the first year. 

Background: One out of every seven women experience depression during pregnancy or within one year of delivery, defined as “perinatal depression”.  This staggering statistic makes perinatal depression the most underdiagnosed obstetric complication in the United States.  If untreated, perinatal depression can have devastating consequences for the mother, their child, and their families.  Research has shown a higher incidence and risk for preterm birth, low birth weight, intrauterine growth restriction, pre-eclampsia, substance use during pregnancy, suicidality and infanticide.

  • Prevalence of perinatal depression is 2x greater in low-income women
  • Perinatal depression can threaten the initial mother-child relationship – i.e. attachment, bonding, breastfeeding
  • Perinatal depression can negatively affect all aspects of a child’s development – lower level of engagement, lower activity level, poor regulation, withdrawal

Last year the U.S. Congress enacted the “21st Century Cures Act”, which included the “Bringing Postpartum Depression Out of the Shadows Act of 2015”.  This law established and expanded pre-existing state funding for maternal depression screening and treatment in primary care settings. The goal was to provide doctors with the training and resources to complete screening, as well provide the follow up support and treatment therapies necessary.

In response to the new federal law, Texas passed the House Bill 2466.  Texas’ new law directs the state agency to develop rules for implementing the maternal depression screening and provide Medicaid coverage for it, regardless of whether the mother is also a recipient of Medicaid.

For guidance, clinicians can review the work done by leaders in Massachusetts to identify women facing perinatal depression and engaging them in appropriate therapies.  The Massachusetts Child Psychiatry Access Project (MCPAP) for Moms developed as a spinoff program of the successful MCPAP launched in 2005.  The original MCPAP was designed to help pediatricians manage pediatric psychiatric needs.  MCPAP for Moms provides three main services: https://www.mcpapformoms.org/

  1. Trainings and toolkits to assist Pediatricians in depressing screening, referral, medication discussions, and other treatment options
  2. Real-time psychiatric telephone consultation for providers caring for pregnant and post-partum women
  3. Networking opportunities with community-based resources to support pregnant and post-partum women

Recommendations/Takehome points: As Pediatricians, we are often the first to see a mother after she leaves the hospital.  We have a unique and important opportunity to identify those struggling with perinatal depression, and get them the help they need and deserve quickly.

  • Perinatal depression screening can be appropriately integrated at the 1, 2, 4, and 6 month visits for the child.
  • It can be as simple as two questions:

Over the past 2 weeks:

(1) Have you ever felt down, depressed, or hopeless?

(2) Have you felt little interest or pleasure in doing things?

  • Screening does not require the Pediatrician to treat the mother. It gives an opportunity to refer her to the appropriate resources.

Alison Kimura, MD, MPH

 

Resources:

  1. http://www.legis.state.tx.us/billlookup/text.aspx?LegSess=85R&Bill=HB2466
  2. https://www.congress.gov/bill/114th-congress/senate-bill/2311?q=%7B%22search%22%3A%5B%22bringing+postpartum+depression%22%5D%7D&r=1
  3. https://www.congress.gov/bill/114th-congress/house-bill/34/actions
  4. https://www.mcpapformoms.org/
  5. http://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1003&context=parentandfamily
  6. Byatt, Nancy, et al. “Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms.” General hospital psychiatry40 (2016): 12-17.
  7. Earls, Marian F., and Committee on Psychosocial Aspects of Child and Family Health. “Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.” Pediatrics5 (2010): 1032-1039.

 

 

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Mental Health Screenings in Adolescent Care

The first week of October every year is designated as Mental Health Awareness Week in the United States – a pattern established by our Congress in 1990 to recognize the efforts of the National Alliance on Mental Illness (NAMI, www.nami.org) and increase awareness about mental health conditions. As we close out the end of Mental Health Awareness Week, I would like to focus on an important topic that sometimes ends up being overlooked or rushed through at a primary care visit: mental health screenings in the adolescent population.

According to results derived from a recent National Comorbidity Survey Replication, nearly 50% of all mental health conditions in the United States begin by age 14. Per data from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), suicide is currently the second leading cause of death in adolescents; 18% of high school students nationwide reported having seriously considered attempting suicide (females > males), and at least 9% had attempted suicide one or more times. Identifying a possible mental health diagnosis early in life — such as depression, anxiety disorders, ADHD, eating disorders, or PTSD — can help save many individuals from life-altering consequences.

The American Academy of Pediatrics (AAP) recommends annual mental health screenings for adolescents starting at age 12. While state Medicaid provisions in Texas previously only allowed for one mental health screening, total, to be billed between the ages of 12 and 18 as part of an annual well-child exam, recent Texas legislation passed on September 1, 2017 (HB 1600) now allows Medicaid reimbursement for up to once-a-year mental health screenings with well-child exams from the ages of 12-18, which is an important step in the right direction.

Texas, however, is currently in the midst of a mental health workforce shortage, especially in child and adolescent psychiatry. Although legislative efforts to address this shortage within the state are in progress, it renders the pediatrician or primary care doctor’s duty to address mental health within adolescent well-child visits absolutely imperative at this moment.

Screening questions/tools that can be used in an adolescent primary care mental health screening can include, but are not limited to:

  • HEADDDSS Assessment:
    • Home – living situation, safety in the home, relationships with family
    • Education/Environment – address any learning/attention difficulties, friends and social circle, school and online bullying, social media (mis)use
    • Activities – hobbies, extracurriculars, jobs
    • Diet – include screening for disordered eating behaviors
    • Drugs:
      • Substance Use Screening Tool: CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
    • Depression/Suicidality:
      • Screening Tools: PHQ-2 (initial screen) + the more detailed PHQ-9
    • Sexual Activity/Sexuality/Sexual Abuse
  • Anxiety Screening Tool: SCARED (Screen for Child Anxiety-Related Emotional Disorders)
  • Trauma Screening Tool: CATS (Child-Adolescent Trauma Screen)
  • Pediatric Symptom Checklists (PSCs)

*Note: Mental health screenings for adolescents under Texas Medicaid must utilize at least 1 of the screening tools approved by Texas Health Steps, which includes the PSCs, the CRAFFT, and the PHQ-9.

For additional mental health information for patients, such as finding the closest behavioral health treatment centers, an excellent resource is the national SAMHSA website at https://www.samhsa.gov/treatment/index.aspx.

Anita Verma, MD

References:
American Academy of Child and Adolescent Psychiatry. (2013). Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care. https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf
American Academy of Pediatrics. (2017). Recommendations for Preventative Pediatric Health Care. Bright Futures, 4th Ed. https://www.aap.org/en‐us/documents/periodicity_schedule.pdf
Centers for Disease Control and Prevention. (2016). Children’s Mental Health Report. CDC Features: Life Stages and Populations. https://www.cdc.gov/features/childrensmentalhealth/
Centers for Disease Control and Prevention. (2016). 1991-2015 High School Youth Risk Behavior Survey data. http://nccd.cdc.gov/YouthOnline/App/Default.aspx
Department of Health and Human Services, Office of Adolescent Health: Adolescent Mental Health Fact Sheets. https://www.hhs.gov/ash/oah/facts-and-stats/national-and-state-data-sheets/adolescent-mental-health-fact-sheets/texas/index.html
HB 1600: Relating to certain mental health screenings under the Texas Health Steps program. http://www.capitol.state.tx.us/BillLookup/Text.aspx?LegSess=85R&Bill=HB1600
Kessler R.C., et al. (2005). Lifetime Prevalence and Age of Onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6): 593‐602. https://www.ncbi.nlm.nih.gov/pubmed/15939837
Testimony of Pritesh Gandhi, MD, MPH, to the Texas House of Representatives Public Health Committee, in support of HB 1600, March 2017. Submitted on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians. https://txpeds.org/sites/txpeds.org/files/documents/house-ph-hb1600-3-14-17.pdf

 

Addressing Nutrition and Childhood Obesity at the Pediatrician’s Office

Childhood obesity is a growing problem that we are battling in the United States. According to data from the Centers for Disease Control and Prevention from 2011 to 2014, 12.7 million children and adolescents were obese in the United States, or every 1 in 6 children. Obesity has been shown to increase the risk of disease in multiple systems of the child’s body:

  • Insulin resistance and Type 2 Diabetes
  • Asthma, sleep apnea, and other respiratory conditions
  • Cardiovascular health- high blood pressure and high cholesterol
  • Musculoskeletal and joint problems
  • Fatty liver disease, gallstones, and heartburn

Furthermore, children with obesity are far more likely to grow up to be adults with obesity. Pediatricians need to vigilantly monitor and treat obesity early.

Identify the Problems at the Office

  • Review growth charts during every visit. Overweight is defined as a BMI between the 85th percentile and the 95th percentile for age and sex. Obesity is defined as a BMI at or above the 95th
  • Ask questions about exercise and nutrition:
    • How many meals a day and what kind of foods? How about snacks?
    • How many cups of juice a day? How about soda?
    • How many servings of fruits or vegetables a day?
    • How many hours of ‘screen time’ a day?
    • How many hours of physical activity a day?

What to Recommend

  • Studies have shown that addressing the issues of screen time, limiting sugary beverages, and increasing activity level are associated with a reduction in BMI.
  • Set goals with advice for your patient, 1 or 2 a visit, for example:
    • Control portion sizes: 3 meals and 2 healthy snacks a day and make half the plate fruits and veggies.
    • Encourage water drinking. Limit juice per day to 4 oz for ages 1-3 yrs, 4-6 oz for ages 4-6 yrs, and 8 oz for ages 7-18 yrs.
    • Encourage at least 5 servings of fruits and vegetables a day. Children can participate by helping to choose fruits or veggies to eat for meal or snack.
    • Limit screen time to 2 hours a day. Remove televisions from the bedrooms and turn off screens during meal times.
    • 60 minutes of physical activity a day. You can take your child to the park every day.

 

Resources and Recipes for Families

References

  1. https://www.cdc.gov/obesity/index.html
  2. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Recommends-No-Fruit-Juice-For-Children-Under-1-Year.aspx
  3. http://texaswic.dshs.state.tx.us/wiclessons/english/recipes/default.asp
  4. https://www.choosemyplate.gov/
  5. https://www.cnpp.usda.gov/2015-2020-dietary-guidelines-americans
  6. Perrin EM, Finkle JP, Benjamin JT. Obesity prevention and the primary care pediatrician’s office. Current opinion in pediatrics. 2007;19(3):354-361. doi:10.1097/MOP.0b013e328151c3e9.

Jennifer Ni, MD

CHIP Re-Authorization

On September 30 of this year congress must act on whether or not CHIP (Children’s Health Insurance Plan) is to be refunded!

What is CHIP?

CHIP is a mostly federally funded insurance program (about 87% federally funded) that provides coverage to over 9 million children in the United States. It is primarily intended for families in the lower to middle classes, meaning those who make enough income to not qualify for Medicaid, but would likely have difficulty affording private insurance. Thus, it is reasonable to assume that if CHIP were to have dramatic alterations that affect its reach that children who would lose coverage or move to an ineffectively expensive model would suffer. CHIP was founded in 1997, at which time 13.9% of American children were uninsured. This number has subsequently decreased to less than 5%.

I, amongst many others, believe it is imperative that congress passes a clean CHIP bill to allow for continued federal funding of CHIP without a significant amount of add-on clauses that would limit its reach. I can think of a multitude of scenarios directly from clinical experience where this would benefit children of lower to middle class families. We frequently encounter young patients with chronic illnesses in everyday practice that would greatly benefit from continuing CHIP. One example of a chronic illness would be asthma. Many families having children inflicted with this illness are covered by CHIP. When severe this tends to result in multiple hospitalizations, ICU stays or even death. These unfortunate outcomes are frequently avoided by dutiful use of prescription medications prescribed on an outpatient basis. Once asthma is staged as more severe, it requires more medication, which ultimately may be unaffordable on a private health insurance plan. If a family, who did not qualify for Medicaid, were to be denied CHIP, I can envision a scenario where many families would not be able to attain the appropriate medications. I can only imagine that this would continue to be a problem and would lead to further complications that may be avoidable.

If funding is not renewed, 31 states would completely run out of the federal funds provided for CHIP by March 2018 with Texas estimated to run out of funding in April 2018. This is an unpalatable fact for the current pediatric patients crucially supported by this program. Please write your local/federal representatives and encourage them to vote for re-funding CHIP without alterations.

Sam Hankins, MD

September 20, 2017

 

 

Promoting Physical Activity in Children: The role of a Pediatrician

Almost everyone, especially medical professionals, would agree that getting regular exercise is good for your health. Many studies have shown that regular exercise decreases the risk of cancer, heart disease, and premature death in general. In children, increased physical activity has been linked to better performance in school. Despite the clear benefits of physical activity on health and other outcomes, few patients report receiving physical activity counseling from their primary care physician. As physicians and leaders in the community, pediatricians should provide appropriate physical activity counseling to their patients, as well support efforts to better assess and address obstacles to regular physical activity in the pediatric population. (more…)

Renewed National Support for Pediatric Cancer Research

When I was in the third grade, my classmate, Jennifer, passed away. It was 1996, and for the past three years, she had fought an uncommon form of leukemia. In the end, she did not live to see her 10th birthday. Each year, over ten thousand children below the age of 19 in the United States will be diagnosed with some form of cancer. Jennifer was by no means alone in her struggle.

The good news is that more and more of these children are becoming success stories. While in 1960, only five percent of children with cancer survived longer than five years, that number has since skyrocketed to over eighty percent. This is excellent news! But as 1,200 children will suffer the same fate as Jennifer in 2017, we must continue to strive to improve our ability to treat and cure cancer.

As pediatricians, we have a responsibility to encourage Congress to increase federal support for pediatric cancer research. Bill HR 820 was introduced in the House by Representative Michael McCaul on 2/2/17, and seeks to “maximize discovery and accelerate development and availability, of promising childhood cancer treatments.” Known as the Childhood Cancer STAR (Survivorship, Treatment, Access, and Research) Act of 2017, this bill seeks to help research efforts through a variety of different ways. First, through the continued and expanded establishment of cancer biorepositories, that researchers would be able to access and study in a laboratory setting. This is an obvious first step, and one that we welcome as an extension of the NIH funding already afforded to research in pediatric oncology.

Second, and critically, the bill amends the Public Health Service Act to state that there must be a pediatric oncologist on the National Cancer Advisory Board, to better advocate for our pediatric patients at the national level.

Additionally, the act sets forth several sections focused on the research of late effects of childhood cancer—an important inclusion, as there will be over 500,000 pediatric cancer survivors by the year 2020. We cannot afford to ignore this population, as well as their impact on the health care system in the future. Similarly, the bill seeks to establish cancer survivorship programs, and offer grants to improve follow-up medical and psychiatric care.

These are all worthy goals, and we will be closely monitoring the progress of this bill. Currently it is in the Subcommittee on Health, but we hope that it will move forward, for the good of all pediatric cancer patients in our country. It is encouraging to see legislation that so directly advocates for children in America.

See the bill here:

https://www.congress.gov/bill/115th-congress/house-bill/820/text?q=%7B%22search%22%3A%5B%22childhood+diabetes%22%5D%7D&r=3#toc-H2E70971C5A7342B4BEB60038512C2ADF

 

Other Sources:

https://www.cancer.gov/types/childhood-cancers

https://www.cancer.org/cancer/cancer-in-children/key-statistics.html

https://www.cdc.gov/nchs/fastats/child-health.htm

 

Call for comments to help FDA with providing nutrition facts to consumers.

An average American is approximately 15 pounds heavier compared to 20 years ago. Height, however, has stayed relatively constant, meaning that our BMI’s are increasing. Unfortunately, children are not immune to this observation. An average 11 year old female has gained more than 11 pounds, and an average 11 year old male has gained more than 13.5 pounds over the past 20 years, leading to the “childhood obesity epidemic” we often hear about in the media. To combat the skyrocketing weight trend, we should write comments to help pass regulations which will increase consumer awareness of various foods’ nutritional values. (more…)

Keep Schools Safe: No place for firearms

In 1990, the country took action to decrease the amount of gun violence present in schools across the nation by passing the federal Gun-Free School Zones Act originally part of the Crime Control Act. Now, a pending bill called the Safe Students Act, H.R. 34, proposes repealing prohibition of guns on school campuses and would threaten that protection. As pediatricians committed to improving children’s health and safety, we must help prevent this dangerous bill from becoming a law. (more…)

Support H.R. 6259 – Protecting Our Kids’ Medicine Act of 2016

Unintentional medication overdoses pose a significant threat to the health of children. I urge pediatricians to ask their Congressional representatives to vote “Yes” on H.R. 6259. The bill would require manufacturers to provide liquid medication dosing devices that are more in conjunction with the recommendations of the American Academy of Pediatrics and the PROTECT Initiative.

Numerous studies document the risks and harm of unintentional overdoses. In 2009, The American Journal of Preventative Medicine published a study entitled “Medication Overdoses Leading to Emergency Department Visits Among Children” that estimated over 70,000 emergency visits were due to medication overdoses each year. The study found that medication error and misuse accounted for 14.3% of the visits, while 82.2% of the visits were due to medication overdoses from unsupervised ingestions. 81.3% of the visits included in the study involved children age 5 and under, and over-the-counter medications were implicated in 33.9% of visits. The study concluded that medication overdoses among children, in particular unsupervised ingestions, represent a substantial burden to the emergency department and to the safety of children.

Furthermore, a 2016 study published in Pediatrics entitled “Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment” found that 84.4% of parents made at least 1 dosing error (defined >20% deviation of the dose), and 68% of these errors resulted in overdosing.  Additionally, 21% of parents made at least one large dosing error (defined as >2 times the dose). The study also found that the use of teaspoon-only labels resulted in a greater number of errors than milliliter-only labels, and that cups were associated with greater number of errors than syringes, especially for larger doses.

In light of the need for new efforts to prevent pediatric medication overdoses, the CDC convened healthcare professional societies, public health agencies, poison control centers, patient/consumer advocates, and OTC medication manufacturers to work together towards preventing unintentional medication overdoses in children. This developed into a medication safety program entitled the PROTECT (Preventing Overdoses and Treatment Errors in Children Taskforce) Initiative. The PROTECT Initiative works to redefine dosing measurements for medications, medication packaging, and patient education to reduce medication errors.

In conjunction with the PROTECT initiative, the American Academy of Pediatrics released a policy statement in March 2015 with recommendations to prevent unintentional medication overdoses. Firstly, the AAP recommends that all oral liquid medications be dosed exclusively in the metric-dosing system with milliliters, only abbreviated as “mL”, as to avoid errors associated with common kitchen spoons. It recommends eliminating labeling, instructions, and dosing devices that contain units other than metric units. In addition, dosing devices should not have extraneous measure markings, and dosing devices should not be significantly larger than the dose described in the labeled dosage to avoid errors. Furthermore, the policy statement states that syringes, optimally designed to partner with flow restrictors, are the preferred dosing device for administering oral liquid medications. For pediatricians, the AAP recommends reviewing milliliter-based dosing and incorporating advance counseling strategies, such as drawings and teach-back methods to educate patients and families on proper medication dosing.

In 2011 the FDA published Guidance for Industry which outlined recommendations to the pharmaceutical industry regarding dosage delivery devices for over-the-counter liquid medications. The Guidance recommends that dosage delivery devices should be included for all liquid oral OTC drug products, delivery devices should be marked with units that correspond to any accompanying instructions, and delivery devices should not have extraneous measure markings, and standard abbreviations should be used. However, the FDA guidance does not standardize labels to milliliter-only labeling, therefore allowing for the more inaccurate teaspoon labeling. In addition, the guidance does not address any flow restrictors to prevent unsupervised ingestions. Furthermore, FDA guidance recommendations are non-binding, and therefore it does not establish legally enforceable responsibilities for manufacturers.

H.R. 6259 would amend the Federal Food, Drug, and Cosmetic Act to ensure that liquid over-the-counter medications are packaged with appropriate dosage delivery devices and, in the case of such medications labeled for pediatric use, appropriate flow restrictors. Pediatricians should ask their representatives to support the bill.  In addition, I urge pediatricians to incorporate advance counseling strategies, such as drawings and teach-back methods to educate patients and families on proper medication dosing. Additional information for families can be found at https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/The-Healthy-Children-Show-Giving-Liquid-Medicine-Safely.aspx, an educational site for parents sponsored by the AAP. As the PROTECT Initiative demonstrates, we need cooperative efforts to prevent medication overdoses in children.

Stephanie Nguyen, MD

 

  1. “FDA Guidance for Industry [PDF – 14 Pages].” Accessed October 24, 2016. http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM188992.pdf.
  2. “The Healthy Children Show: Giving Liquid Medicine Safely …” Accessed October 24, 2016. https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/The-Healthy-Children-Show-Giving-Liquid-Medicine-Safely.aspx.
  3. “H.R.6259 – Protecting Our Kids’ Medicine Act of 2016.” Congress.gov. Accessed October 24, 2016. https://www.congress.gov/bill/114th-congress/house-bill/6259?resultIndex=88.
  4. “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications.” Pediatrics 135, no. 4 (2015): 784-87. doi:10.1542/peds.2015-0072.
  5. “The PROTECT Initiative: Advancing Children’s Medication …” Accessed October 24, 2016. http://www.cdc.gov/medicationsafety/protect/protect_Initiative.html.
  6. Schillie, Sarah F., Nadine Shehab, Karen E. Thomas, and Daniel S. Budnitz. “Medication Overdoses Leading to Emergency Department Visits Among Children.” American Journal of Preventive Medicine 37, no. 3 (2009): 181-87. doi:10.1016/j.amepre.2009.05.018.
  7. Yin, H. S., R. M. Parker, L. M. Sanders, B. P. Dreyer, A. L. Mendelsohn, S. Bailey, D. A. Patel, J. J. Jimenez, K.-Y. A. Kim, K. Jacobson, L. Hedlund, M. C. J. Smith, L. Maness Harris, T. Mcfadden, and M. S. Wolf. “Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment.” Pediatrics 138, no. 4 (2016). doi:10.1542/peds.2016-0357.

Is the rising cost of prescription drugs preventing patients from accessing life-saving medication?

Prices of prescription drugs in the United States are among the highest in the world. Most recently, the skyrocketing price of the epinephrine pen, EpiPen, has been the subject of major news headlines. Many have been enraged by the dramatic price increase of the EpiPen ($100 to over $600 in the span of a few years). Unfortunately, the EpiPen is one of many prescription drugs that has been affected by such dramatic inflation. Many fear that the rising cost of life-saving medication will limit access to those who need it. Healthcare providers cannot stand idly as these changes negatively impact patients. We need to have a better understanding of the prescription drug industry so that we can find reasonable solutions for our patients. (more…)