Implementing social and emotional screening tools in your practice

Interview transcript (Edited for clarity):

Marian F. Earls, MD, MTS, FAAP:

I'm Marian Earls,I'm a general pediatrician and a developmental behavioral pediatrician and I've done work around practice transformation for years, and how do we integrate mental health principles into pediatric practice. So currently, I'm the Council Chair for the Council on Healthy Mental and Emotional Development for the AAP. In my own state, I've done a lot of work with practices on just those topics.

Kori Flower, MD, MS, MPH, FAAP:

I'm Kori Flower, and I'm a general pediatrician, and division chief of General Pediatrics and Adolescent Medicine at the University of North Carolina at Chapel Hill. I've had the pleasure of working with Dr. Earls for quite a long time and in many practices on implementing early childhood screenings in general. So I'm happy to be working on what we might call this most recent frontier in implementing social and emotional screening.

Contemporary Pediatrics:

Can you explain your session on screening for social and emotional health, presented at AAP 2023?

Flower:

Well, I think we elected to present on social and emotional screening tools in primary care. The reason for that is that, as I mentioned, social and emotional screening is an area that we didn't always screen for, but we knew we should. That's because as pediatricians we've become pretty good at developmental screening, meaning picking up where their children are walking and talking and being with developmental milestones on time. But even when we do that, it's not as effective at picking up the early kind of social, emotional and behavioral challenges that children are facing. But it's really important that we do that, because probably half of mental and behavioral health conditions are going to emerge at the time that kids are 14 years old, and so we're seeing those kids in our practice. That means it's an opportunity to to do something early, as long as we're able to screen and then identify and put interventions into place for kids that need them early, and have a chance at changing the trajectory of the development of mental health problems and hopefully prevent some of them.

Earls:

And we presented screening as something that you do that initiates a conversation with families, right? So families may not know that some of these things they're thinking about are something they can bring up with pediatricians. So we're asking these screening questions before the visit, telling families that we ask everyone these questions and then when we're going into the room and talking to the family, then we know what's on their mind. So it's very important, because then it helps us with our conversation in engaging families. So it's a very important piece to be integrated right into how we do every single visit with a family and how do we support them. It's not just about finding, whether there's something that's wrong, or there's some deficit, it's also about identifying what are strengths and what things are going well, and to be able to celebrate that with the family. It really solidifies the pediatrician family relationship, to be able to do these things.

Contemporary Pediatrics:

What age ranges did your session focus on? How critical are mental health screenings in these various ages?

Earls:

The screening we talked about really went from 0 to 21, essentially. We didn't dwell a lot today on the adolescents. People have really learned about screening about depression and anxiety and screening specifically for suicidality. We're really trying to get people to think about, again, mental health from the very beginning and identify things, as Kori mentioned, to identify things early. So there may be signs of things happening for kids who are school-aged kids, right? And a family might say, "well, we see some of these things at home, or they're saying that they see some of these things at school, or my child seems to not be as engaged as they used to be," or something like that. So we have that opportunity to identify stuff a lot earlier.

Flower:

Just building on that,I think we had identified that there is some good screening that many pediatricians are now doing for the adolescent, so 12 [years] and up, and our work today focused on addressing a gap that is really in social and emotional behavioral screening in those children under 12, where relatively little is happening right now, but can make it a really positive difference both in identifying issues but also, as Marian has said, and that longitudinal relationship building activity that we're doing with families. Especially since we have such frequent contact with families in the first 5 years of life.

Contemporary Pediatrics:

What are the downstream effects of waiting to screen children for social and emotional health?

Earls:

If we wait until downstream, if we wait until there's a crisis, we've missed this opportunity to begin addressing that, and to give families the, the strategies,to address things very early, I mean, that's what we miss. The horrible consequences what we're hearing about, the rates of suicide between 10 and 24 years,I mean, it's the second-leading cause of death in that age range. When I tell people that they're quite shocked. So I have colleagues who have had children as young as 8 or 9, describe to them what their suicide plan is. So that's very real. We do have the advantage of that longitudinal relationship with pediatricians. We often have been with this family from infancy on. So we have that opportunity to really identify, is this child being severely bullied, is this child having anxiety? Are there things that we might be able to address before we get to that point?

Flower:

I would say one of the other downstream of not screening is that the problems that Marian just described will come out anyway. Yes, it's one of the other downstream effects of not screening is that the problems that Marian just described will come out anyway. So if we don't have a systematic approach for identifying them at the beginning of the visit, and helping prioritize the visit time around that, they're likely to come up at the end of the visit, or at some other time. So that's also called doorknob questions. So I think we found that systematic social and emotional and behavioral screening at the beginning of the visit helps to bring those things to the to the surface at the beginning so the visit can really be centered around those concerns, particularly when they're serious. It's also really helpful and important to do it at the beginning of the visit with everybody, for reasons of equity. We find that when families get the same screening tool all the time, it's really helpful for acknowledging that everyone has equal opportunity to to have these challenges arise, and also to have them addressed.

Earls:

And you start from the beginning, letting people know that this is a conversation we can have. Right? So a colleague of mine talked about, in his practice, a mother who didn't have perinatal depression, but said to him, when her child was like a year of age, she says, "You know, I knew I know, you came to the right practice, because you always asked me when I came for those infant visits." So we're also having an impact by by making it okay to have these conversations right from the beginning.

Contemporary Pediatrics:

What do you hope pediatricians walk away with after attending your session?

Earls:

That people be less about "how do I fit in that screening tool, which screening tools they want?" I mean, obviously, they need to do that. But really, I hope, the message of the conversation of building that relationship and having that conversation, I hope that's what they walk away with, and feeling comfortable, being able to talk about these things that support families. The screening tools or help initiate the conversation, but the conversation is important pieces.

Flower:

I would say one of the most important things is that these screening activities lay the groundwork for future conversations, so a fairly similar answer. So in other words, each time we screen or have a conversation about screening, even if there's nothing wrong today on the day that screening is done, the idea is that it plants a seed for a future conversation, and has strengthened a relationship so the family knows they can come back when challenges do emerge.