Welcome to the training on Behavioral Health: Screening and Intervention provided by Texas Health and Human Services (HHS) and the Texas Department of State Health Services (DSHS).
Notes: For purposes of this module,
- The term “serious emotional disturbance” (SED) is used to describe a range of mental, emotional, and behavioral disorders.
- The term “children” refers to children and adolescents ages birth through 20 years.
- The term “parent” includes guardians and caregivers.
- References and links mentioned in this module can be found in the Appendix of Resources.
The goal of this module is to equip Texas Health Steps providers and other interested health-care professionals to follow state requirements and best practices for psychosocial and behavioral health screening, diagnosis, and ongoing management in the primary care setting.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Specify risk factors and diagnostic criteria for common forms of serious emotional disturbance.
- Apply the requirements of the Texas Health Steps Periodicity Schedule to conduct age-appropriate mental health screening for children and adolescents from birth through 20 years using approved tools.
- Integrate age-appropriate anticipatory guidance and evidence-based prevention strategies into clinical practice.
- Summarize the primary care provider’s role in coordinating care for children and adolescents with behavioral health disorders.
Please note this module expires on 6/21/2021.
This module was released on 6/21/2018.
Continuing Medical Education
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Texas Medical Association (TMA) through the joint providership of The Texas Department of State Health Services, Continuing Education Service and Texas Council of Community Centers. The Texas Department of State Health Services, Continuing Education Service is accreditated by TMA to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Nursing Education.
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Social Work Education.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.50 hour(s) for attendance.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
- Ask Suicide-Screening Questions (ASQ) Toolkit: Free resource that can help primary care providers identify youth at risk for suicide. From the National Institute of Mental Health (NIMH).
- Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. (2017). From the American Academy of Pediatrics (AAP).
- Facts for Families Guide: Information on a host of mental health-related topics. From the American Academy of Child & Adolescent Psychiatry (AACAP).
- Guideline for Prescribing Opioids for Chronic Pain: Recommendations for prescribing opioid pain medication for patients 18 and older in primary care settings. From the Centers for Disease Control and Prevention (CDC).
- healthychildren.org: Resources to support parents and promote positive parenting, including a Family Life section. From the AAP.
- Medications for mental health disorders: Learn more about commonly used medications for specific mental health disorders. From the NIMH.
- MentalHealth.gov: Resources for mental health issues, including the basics, what to look for, talking about mental health, and how to get help. From the U.S. Department of Health and Human Services.
- Mental Health Rating Scales:
- CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) Behavioral health screening tool recommended by the AAP Committee on Substance Abuse for adolescents ages 20 and younger. CRAFFT consists of a series of six questions to simultaneously screen for those at high risk for alcohol and other drug use disorders. The responses indicate whether a longer conversation about the use, frequency, and other risks and consequences is warranted.
- Patient Health Questionnaire (PHQ-9) Multipurpose instrument for screening, diagnosing, and measuring the severity of depression. The PHQ-9 is completed by the patient and scored by the clinician. The questionnaire can be administered repeatedly to reflect improvement or worsening in response to treatment.
- Pediatric Symptom Checklist (PSC) Psychosocial screen to improve the recognition of cognitive, emotional, and behavioral problems in children ages 4 to 16. The PSC consists of 35 items that are rated never, sometimes, or often. A “positive” score indicates the need for further evaluation and/or intervention. Youth-reported and parent-completed versions are available.
- Mental Health Screening and Assessment Tools for Primary Care: Table of mental health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations, costs, and references. From the AAP.
- Patient-Reported Outcomes Measurement Information System (PROMIS): Set of freely available validated measures of physical, mental, and social well-being. From the National Institutes of Health (NIH).
- Postpartum Depression Kit: Free resource for the screening, diagnosis, and treatment of PPD. From the Texas Health and Human Services Commission (HHSC).
- Postpartum Depression Screening Tools: Validated for use in PPD patients and available online. From Texas Health Steps.
- Standardized Assessment Tools: Free repository of available standardized tools to assess mental and physical conditions. From the National Cancer Institute (NCI).
- Suicide Prevention Mobile Apps: Download the free ASK about Suicide and Hope Box apps. From the Texas Suicide Prevention Council.
Texas Mental Health Programs and Services
- Children’s Health Insurance Program (CHIP): Designed for low-income families who lack access to health insurance and don’t qualify for Medicaid.
- Early Childhood Services (ECI): Diagnosis of a disability or developmental delay, including autism spectrum disorder (ASD), qualifies a child for ECI services through age 35 months. To refer families for services, use the online form developed by ECI and the Texas Pediatric Society. Families can also contact the ECI program by calling the Texas HHSC Office of the Ombudsman at 877-787-8999, choose a language, and then select Option 3.
- Mental Health First Aid (MHFA): Learn more about training and class availability from Texas local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs).
- Texas Council of Community Centers: Community Mental Health Services for adults and children is administered through 39 local mental health authorities (LMHAs) throughout the state. Visit the group’s website for a map showing service areas and a listing of center addresses and contact information for mental health authorities (LMHAs).
- Texas Education Agency (TEA): In Texas, school district Preschool Programs for Children with Disabilities (PPCD) provide special education and related services for eligible children ages 3 through 5 with disabilities. Eligible children may receive PPCD services in a variety of places.
- Texas Health and Human Services Commission (HHSC): Plays a major role in the funding and oversight of publicly funded mental health care, including coverage for mental health services for children through Medicaid and CHIP.
- Texas Health Steps: The Texas Health Steps Periodicity Schedule, Child Health Clinical Health Records, Anticipatory Guidance, and other information and forms for health-care providers are available on the Texas Health Steps Provider Information web page.
- Texas Medicaid: Delivered and managed through a variety of providers, including STAR Medicaid, STAR+PLUS Medicaid and STAR Kids managed care programs, and Medicaid fee-for-service programs.
- Texas Medicaid & Healthcare Partnership (TMHP): Information for Medicaid providers, including the Texas Medicaid Provider Procedures Manual (TMPPM).
- Texas Mental Health and Substance Abuse Division (MHSA): Oversees the mental health system in Texas.
Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., & Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870–877.
American Academy of Child & Adolescent Psychiatry (AACAP):
- A guide to building collaborative mental health care partnerships in pediatric primary care. (2010).
- Han, B., Compton, W. M., Blanco, C., Colpe, L., Huang, L., & McKeon, R. (2017). National trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 20–27: e2.
- Merikangas, K. R., He, J., Burstein, M., Swanson, S., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2011). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989.
- Panic disorder in children and adolescents. (2013).
- Schizophrenia. (2013).
- Workforce issues. (2016).
- Workforce maps by state. (2015).
American Academy of Pediatrics (AAP):
- 10 things parents can do to prevent suicide. (2015). Committee on Psychosocial Aspects of Child and Family Health.
- Addressing early childhood emotional and behavioral problems. (2016).
- Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. (2017).
- Calzo, J. P., Sonneville, K. R., Scherer, E. A., Jackson, B., & Austin, S. B. (2016). Gender conformity and use of laxatives and muscle-building products in adolescents and young adults. Pediatrics, 138(2): e20154073.
- Children’s hospitals admissions for suicidal thoughts, actions double during past decade. (2017). AAP News.
- Council on Injury, Violence, and Poison Prevention Executive Committee. (2012, reaffirmed December 2016). Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics, 130(5).
- Fortuna, R. J., Robbins, B. W., Caiola, E., Joynt, M., & Halterman, J. S. (2010). Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics, 126(6), 1108–1116.
- Fowler, K. A., Dahlberg, L. L., Haileyesus, T., Gutierrez, C., & Bacon, S. (2017). Childhood Firearm Injuries in the United States. Pediatrics, June 2017, e20163486.
- How emotional and behavioral disorders are treated. (2015).
- Kulig, J. W. & Committee on Substance Abuse. (2005). Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics, 115(3).
- Mental health initiatives.
- Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6).
- Study: Gunfire kills or injures more than 7,000 children per year. (2017).
American College of Obstetricians and Gynecologists (ACOG). (2013). Postpartum Depression: When does postpartum depression occur?
American College of Pediatricians (ACP). Marijuana use: Detrimental to youth. (2017).
American Psychiatric Association (APA):
- Duckworth, K. (2015). Understanding Mental Disorders: Your Guide to DSM-5. American Psychiatric Publishing.
- Knoll, J. L. & Annas, G. D. (2016). Mass Shootings and Mental Illness. American Psychiatric Association Publishing.
- What are disruptive, impulse-control and conduct disorders? (2018).
- What is mental illness? (2015).
American Psychological Association. (n.d.). Children’s mental health.
American Society of Addiction Medicine. (2016). Opioid addiction facts & figures.
Anxiety and Depression Association of America. (2015). Childhood anxiety disorders.
Bartlett, J. (2014). Childhood-onset schizophrenia: What do we really know? Health Psychology and Behavioral Medicine, 2(1), 735–747.
Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., Fernandez, T., & Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive Behavioral Practice, 22(1), 5–19.
Bergink, V., Rasgon, N., & Wisner, K. L. (2016). Postpartum psychosis: Madness, mania, and melancholia in motherhood. The American Journal of Psychiatry, 173(12), 1179–1188.
- Child and adolescent psychiatry and mental health (compilation of articles).
- Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and Adolescent Psychiatry and Mental Health, 11(5).
Boston University, Center for Anxiety & Related Disorders. (n.d.). Specific phobias in children and adolescents.
Brady Center to Prevent Gun Violence. (2015). The truth about suicide & guns.
Centers for Disease Control and Prevention (CDC):
- Adolescent health. (2017).
- Attention-deficit/hyperactivity disorder (ADHD): Other concerns & conditions. (2018).
- Autism spectrum disorder. (2017).
- Data and statistics: Mental, behavioral, and developmental health of children aged 2–8 years. (2017).
- Depression among women. (2017).
- Guideline for prescribing opioids for chronic pain. (2017).
- Mental health of children aged 3–17 years. (2017).
- QuickStats: Percentage of children and adolescents aged 4–17 years with serious emotional or behavioral difficulties, by poverty status and sex — National Health Interview Survey, 2011–2014. (2015). Morbidity and Mortality Weekly Report, 64(46), 1303.
- Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016). Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50–51), 1445–1452.
- Smoking and tobacco use. (2017).
- Suicide among youth. (2017).
- Youth Risk Behavior Surveillance, United States. (2015).
- Youth violence: Risk and protective factors. (2017).
Child Mind Institute:
- Children’s Mental Health Report. (2016).
- Conduct disorder basics. (n.d.).
- How anxiety leads to disruptive behavior. (n.d.).
Colino, S. (2016). The hidden risks of eating disorders in guys. U.S. News & World Report, November 23.
Diamond, G. S., Herres, J. L., Krauthamer Ewing, E. S., Atte, T. O., Scott, S. W., Wintersteen, M. B., & Gallop, R. J. (2017). Comprehensive screening for suicide risk in primary care. American Journal of Preventive Medicine, 53(1), 48–54.
Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66(9), 1013–1021.
Gochman, P., Miller, R., & Rapoport, J. L. (2011). Childhood-onset schizophrenia: The challenge of diagnosis. Current Psychiatry Report, 13(5), 321–322.
Interdepartmental Serious Mental Illness Coordinating Committee. (2017). ISMICC report to congress. The way forward: Federal action for a system that works for all people living with SMI and SED and their families and caregivers.
Kaplan, Y. C., Keskin-Arslan, E., Acar, S., & Sozmen, K. (2017). Maternal SSRI discontinuation, use, psychiatric disorder and the risk of autism in children: A meta-analysis of cohort studies. British Journal of Clinical Pharmacology, 83(12), 1298–2806.
Lebel, C., Walton, M., Letourneau, N., Giesbrecht, G. F., Kaplan, B. J., & Dewey, D. (2016). Prepartum and postpartum maternal depressive symptoms are related to children’s brain structure in preschool. Biological Psychiatry, 80(11).
Meadows Mental Health Policy Institute and Texas Conference of Urban Counties. (2016). Texas mental health landscape.
Mental Health America:
- Mental health information. (n.d.).
- Conduct disorder. (n.d.).
- The state of mental health in America. (2017).
Merck Manual. (2017). Overview of mental disorders in children and adolescents.
Munir, K. M. (2016). The co-occurrence of mental disorders in children and adolescents with intellectual disability/intellectual developmental disorder. Current Opinion in Psychiatry, 29(2), 95–102.
National Alliance on Mental Illness (NAMI):
National Association of Anorexia Nervosa and Associated Disorders (ANAD). (n.d.). Eating disorder statistics.
National Council for Behavioral Health (NCBH):
- Congressional briefing highlights children’s mental health. (2017).
- Mental Health First Aid. (n.d.).
National Eating Disorders Association (NEDA). (n.d.). Binge eating disorder: Overview and statistics.
National Institute for Health Care Management (NIHCM). (2009). Issue paper: Strategies to support the integration of mental health into pediatric primary care.
National Institute of Mental Health (NIMH):
- Autism spectrum disorder. (2017).
- Bipolar disorder. (2016).
- Child and adolescent mental health. (2017).
- Eating disorders. (2017).
- Intramural researchers develop suicide risk screening toolkit for medical settings. (2018). Science Update.
- Major depression. (2017).
- Mental illness. (2017).
- National survey confirms that youth are disproportionately affected by mental disorders. (2010). Science Update.
- Pediatrics-based brief therapy outdoes referral for youths with anxiety and depression. (2017). Science Update.
- Postpartum depression facts. (n.d.).
- Schizophrenia. (2017).
- Symptoms outdo diagnoses in predicting bipolar disorder in at-risk youth. (2016). Science Update.
- Treatment of children with mental illness. (2009).
National Institute on Drug Abuse (NIDA):
- Principles of drug addiction treatment: A research-based guide. (2018).
- Trends and statistics. (2017).
National Institutes of Health (NIH). (2015). Patient-Reported Outcomes Measurement Information System (PROMIS).
National Research Council-Institute of Medicine (NRC-IOM). (2009). Preventing mental, emotional, and behavioral disorders among young people. National Academies Press.
Office of the U.S. Surgeon General. (2018). The facts on e-cigarette use among youths and young adults.
Olfson, M., Druss, B. G., & Marcus, S. C. (2015). Trends in mental health care among children and adolescents. New England Journal of Medicine, 372, 2029–2038
Olfson, M., King, M., & Schoenbaum, M. (2015). Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry, 72(9), 867–74.
Ornoy, A. & Koren, G. (2017). Selective serotonin reuptake inhibitors during pregnancy: Do we have now more definite answers related to prenatal exposure? Birth Defects Research, 109(12), 898–908.
Ringeisen, H., Stambaugh, L., Bose, J., Casanueva, C., Hedden, S., Avenevoli, S., Blau, G., Canino, G., Carter, A., Colpe, L., Copeland, W. E., Fisher, P. W., Kaufman, J., Merikangas, K., Narrow, W., Stroul, B., & West, J. (2016). Measurement of childhood serious emotional disturbance: State of the science and issues for consideration. Journal of Emotional and Behavioral Disorders, 25(4), 195–210.
Schrobsdorff, S. (2016, November 16). There’s a startling increase in major depression among teens in the U.S. Time.
Shrivastava, A., Johnston, M., & Tsuang, M. (2011). Cannabis use and cognitive dysfunction. Indian Journal of Psychiatry, 53(3), 187–191.
Smink, F. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406–414.
Society of Clinical Child & Adolescent Psychology. (2017). Therapy or medication?
Substance Abuse and Mental Health Services Administration (SAMHSA):
- Center for Behavioral Health Statistics and Quality. (2016). DSM-5 changes: Implications for child serious emotional disturbance (unpublished internal documentation).
- Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. (2017).
- Populations at risk for suicide. (2017).
- Substance use disorders. (2015).
Texas Department of Family and Protective Services (DFPS) and The University of Texas at Austin College of Pharmacy. (2016). Psychotropic medication utilization parameters for children and youth in foster care (5th version).
Texas Department of State Health Services (DSHS). Mental health services for children and adolescents. (2016).
Texas Health and Human Services Commission (HHSC):
- Community Resource Coordination Groups (CRCGs) of Texas handbook. (2016).
- Postpartum depression among women utilizing Texas Medicaid. (2016).
- Postpartum depression kit. (2017).
Texas System of Care:
- A better future for Texas children: The impact of System of Care. (n.d.).
- Achieving a Texas System of Care: Final evaluation report. (2018).
- Achieving well-being for children and youth. (2012). Brochure.
The Incredible Years. (n.d.).
The Nemours Foundation. (2018). Postpartum depression.
Tobin, E. T., Hulkower, R. L., & Kaminski, J. W. (2017). Behavioral health integration in pediatric primary care: Considerations and opportunities for policymakers, planners, and providers. Milbank Memorial Fund report.
U.S. Department of Health and Human Services:
- Adolescent mental health disorders. (2016).
- Agency for Healthcare Research and Quality (AHRQ). (2017). Behavioral and mental health.
- Office on Women’s Health. (2017). Depression during and after pregnancy.
Vo, M., Lau, J., & Rubinstein, M. (2016). Eating disorders in adolescent and young adult males: Presenting characteristics. Journal of Adolescent Health, 59(4), 397–400.
Wissow, L. S., van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children’s mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113.
World Health Organization:
The medical definitions provided in this module were obtained or adapted from Merriam-Webster and the Mayo Clinic.
Teen Consent and Confidentiality
Establish practice guidelines that comply with legal requirements for obtaining consent and maintaining confidentiality in providing health-care services to adolescents.
Gain communication skills that can be used in the primary care setting to motivate children, adolescents, and families to make positive health changes, improve self-care for chronic conditions, and avoid high-risk behaviors.
Promoting Adolescent Health
Adopt best practices for adolescent screening, including recommended schedules, effective communication, and enhanced clinical procedures. Includes video examples of effective screening techniques.
Introduction to Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Learn how to conduct SBIRT in the medical office: instituting routine screening, early intervention, and referral to treatment for adolescent patients with substance use disorders or at risk for developing such disorders. Provides resources for obtaining mandatory SBIRT training.
Texas Health Steps Guidance
Texas Health Steps Guidance
Anticipatory guidance—age-appropriate education and counseling—is a required component of every Texas Health Steps preventive medical and dental checkup. Texas Health Steps offers age-appropriate education and counseling topics so providers can assist patients, families, and caregivers to understand growth, development, and healthy practices. Texas Health Steps recommends that health-care providers personalize anticipatory guidance depending on the needs of their patients. Anticipatory guidance topics should be individualized and prioritized based on questions and concerns of the child or adolescent and their parent or guardian. Specific guidance should also be based on findings obtained during the health history and physical exam.
Texas Health Steps offers Anticipatory Guidance-A Guide for Providers, which includes guidance topics for every age group birth through 20 years. It mirrors anticipatory guidance topics included on the Texas Health Steps Child Health Clinical Record Forms.
Families and caregivers of children with chronic medical conditions face complex challenges and extended stress. Providing long-term care for a child with a disability or chronic illness can take a physical, emotional, and financial toll. It also requires a time commitment that can be difficult to achieve.
As a pediatric health-care provider, you “have a responsibility to recognize caregiver burden (Adelman, Tmanova, Delgado, Dion & Lachs, 2014). Research has shown that caregivers are at increased risk for depression, anxiety, and other negative health effects of what can be a crushing responsibility. At each pediatric checkup, make it part of your routine to inquire whether family or caregivers have questions or concerns about their roles, their own health, or navigating the health-care system.
The health of your young patients and the health of their caregivers are interwoven.
Caregivers who feel overwhelmed may not be able to provide appropriate care for a child in need. You must be alert to outcries for help or signs of health problems related to caregiving, including loss of sleep and diet imbalance. Open communication allows you to be a sounding board for caregivers who are struggling with their duties. At the same time, be on the watch for signs of fatigue or stress in caregivers who try to project an “all’s well” attitude even when they are having problems.
Your role includes providing practical counseling about stress and offering resources designed to help families and caregivers cope.
Top 10 Caregiver Coping Skills
Sharing this Top Ten list of coping skills can help caregivers learn strategies that may reduce stress:
- Understand your feelings.
- Express your emotions.
- Educate yourself about your child’s illness or condition.
- Keep communications open.
- Talk to other parents.
- Focus on the strengths and goals that are achievable.
- Believe in your child.
- Establish routines.
- Maintain your sense of humor! There is no co-pay for laughter!!
- Remember that taking care of yourself is caring for your family.
Source: Parent to Parent of New York State
Resources to share with families and caregivers
Aging and Disability Resource Centers (ADRCs) operated by Texas Health and Human Services (Texas HHS). The centers are welcoming and offer information about state and federal health benefits as well as local programs and services. The trained staff can connect caregivers with services such as home care, meals, transportation, legal help, attendant care, respite support, and housing. Visit the ADRC website for a list of resource center locations in Texas.
Family Support Services, a program to help families care for children with special health-care needs at home. Services are provided by the Children with Special Health Care Needs (CSHCN) Services Program, a branch of the Texas Department of State Health Services.
Navigate Life Texas, a multilingual website created by parents for parents of children with disabilities and special health-care needs. This unique site offers comprehensive, relevant, and reliable information for families, professionals, advocates, and anyone working with children who have disabilities and their families. Sponsored by the Texas Interagency Task Force on Children with Special Needs.
Take Time Texas, a website offered by Texas HHS that includes a state inventory of respite services.
Texas Parent to Parent offers peer support for parents of children with special health-care needs.
All Medicaid managed care organizations (MCOs) provide case management services (called service management for STAR members with special health-care needs). In the other Medicaid managed care programs, everyone gets some level of case management. Patients should first be referred to the plan’s service coordinator and then referred to Case Management for Children and Pregnant Women if patient needs cannot be met by the plan’s services. Health plans are also required to make appropriate referrals to case management services.
For patients enrolled in STAR Medicaid, STAR Health, or Fee-For-Service (FFS) Medicaid, providers can make a referral by one of these methods:
- Calling 877-847-8377 (877-THSteps).
- Contacting a case manager (“Find a Case Manager” web page accessed from the Resources for this module).
- Submitting the Case Management Referral Form (the form is also accessed from Resources).
For patients enrolled in STAR Kids:
- Health Plan service coordinators and others can refer by submitting the STAR Kids Case Management Request Form (the form is also accessed from Resources).
Early Childhood Intervention (ECI) is a statewide program for families with children birth through 35 months who have disabilities and developmental delays. All health-care providers are required by federal and state regulations to refer children 35 months and younger to the local ECI program as soon as possible but no later than seven days after the suspicion or identification of a developmental delay.
To qualify for ECI services, a child must have:
- A qualifying medically diagnosed condition that has a high probability of resulting in a developmental delay. For more information, visit the ECI Qualifying Diagnosis Search web page.
- An auditory or visual impairment as defined by the Texas Education Agency (TEA) rule at 10 TAC Section 89.1040.
- A documented delay of at least 25 percent in one or more of the following areas of skills and development: gross motor, communication, cognition, fine motor, social, emotional, or self-help. Or, a documented delay of at least 33 percent when the delay occurs only in expressive language.
- A qualitative determination of delay, as indicated by responses or patterns that are disordered or qualitatively different from what is expected for the child’s age.
To refer a child, providers should use the ECI Provider Referral and Feedback form. The form, which requires a parent or guardian signature, helps ensure that ECI’s evaluation results and service plan are shared with the referring provider.
To refer families for services, providers can call the local ECI program.
Texas Health Steps requires that all federal- and state-mandated checkup components be documented in the medical record in order for the checkup to be considered complete and to qualify for provider reimbursement. Any checkup component that is not completed must be noted in the medical record, along with the reason it was not completed and a plan to complete it. The medical record must also contain documentation of all screening tools used, screening results, and referrals. Texas Health Steps child health clinical record forms are optional but are recommended to assist providers with documentation of all required checkup components. Providers should be aware that Texas Health Steps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation.
A medical home is the patient’s primary point of contact when accessing health care. The medical home concept was developed by the American Academy of Pediatrics (AAP) and is promoted by Texas Health Steps. A medical home is defined as one in which care is accessible, family-centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. It is a partnership between a child, the family or caregiver, and the child’s primary health-care setting. The primary health-care setting can be a physician’s office, a hospital outpatient clinic, a school health center, a community health center, or a health department clinic.
Providers who need assistance finding a specialist or subspecialist who accepts patients enrolled in Medicaid can find a specialist or subspecialist by using the Texas Medicaid & Healthcare Partnership (TMHP) Online Provider Lookup or by calling the Texas Health Steps toll-free help line for providers at 800-964-2777 Monday through Friday from 8 a.m. to 6 p.m. Central Time. Select option 3 to speak with a representative.
Providers can access a set of child health clinical record forms to document Texas Health Steps preventive medical checkups. The set includes a form for each checkup under the Texas Health Steps Periodicity Schedule, for patients from up to 5 days old through 20 years. Providers can save or print the forms.
Each form includes the required components for that age’s checkup, along with space for documenting routine, non-required components of a medical checkup. The backside of the form includes a helpful list of suggested anticipatory guidance topics and checklists such as the Hearing Checklist for Parents and Lead Risk Factors.
Texas Health Steps is the preventive care services program for children birth through 20 years who are enrolled in Medicaid. Texas Health Steps provides regular checkups and screenings as part of the Early and Periodic Screening, Diagnosis, and Treatment program, also known as EPSDT.
In Texas, EPSDT is known as Texas Health Steps, which includes the preventive care components—or Early and Periodic Screening (EPS)—of the total EPSDT service. Required medical checkups and preventive care services are provided in accordance with the latest Texas Health Steps Periodicity Schedule, which is modeled after the one developed by the American Academy of Pediatrics (AAP). Additional checkup components are required in Texas to meet federal and state guidelines, and checkups are encouraged as part of the medical home. The Periodicity Schedule specifies when each of the checkup components is due. Providers should always refer to the latest schedule available. To download a PDF of the Periodicity Schedule online, visit the Texas Health Steps Provider Information web page.
The Texas Medicaid & Healthcare Partnership (TMHP) updates the TMPPM monthly. The policy updates are published on the TMHP website and in banner messages, which appear weekly on a provider’s Remittance and Status Report as well as on the website. Providers can find updates on the web page in two ways:
Release Notes—Changes to the TMPPM arranged by date, with most recent at the top of the list.
Change History—Changes to the TMPPM arranged by chapter. (If a chapter has not changed, it will not appear on the list).
NOTE: Providers should always check the TMHP website for the current TMPPM, banner messages, and policy and procedures updates. Archived versions of the TMPPM will remain online for reference purposes.