2019 MBHR Measure: Screening and monitoring for psychosocial problems among children and youth

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Screening and monitoring for psychosocial problems among children and youth
NQS Domain Effective Clinical Care
Measure ID MBHR5
NQF ID N/A
Measure Type Patient Reported Outcome (PRO)
High Priority? Yes
Description Percentage of children from 3.00 to 17.99 years of age who are administered a parent-report, standardized and validated screening tool to assess broad-band psychosocial problems during an intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 6 months after initial positive screen for externalizing and internalizing behavior problems.
Denominator DENOMINATOR (SUBMISSION CRITERIA 1):
Patients 3 to 17 years of age who are administered a parent-report, standardized screening tool.

DENOMINATOR (SUBMISSION CRITERIA 2):
i. Patients 3 to 17 years of age who are administered a parent-report version of the Pediatric Symptom Checklist Externalizing Subscale (PSC-ES) (score above 6 points)
ii. Patients 3 to 17 years of age who are administered a parent-report version of the Pediatric Symptom Checklist Internalizing Subscale (PSC-IS) (score above 4 points)

Denominator Exclusions: None

Denominator Exceptions: Patients who present an acute condition or crisis during the intake visit who are not administered a behavior problem screener.

Numerator NUMERATOR (SUBMISSION CRITERIA 1):
Patients who were administered a psychiatric or behavioral health intake visit to assess broad-band psychosocial problems.

NUMERATOR (SUBMISSION CRITERIA 2):
i. Patients who were administered a psychiatric or behavioral health intake visit with a positive PSC-ES screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-ES assessment taken 2 to 6 months later.
ii. Patients who were administered a psychiatric or behavioral health intake visit with a positive PSC-IS screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-IS assessment taken 2 to 6 months later

Numerator Exclusions: None

Data Source Claims, EHR, Paper Medical Record, Registry
Meaningful Measure Area Patient Reported Functional Outcomes
Meaningful Measure Rationale Screening for psychosocial problems in children and adolescents, one of the most common morbidities for children of this age, will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life by identifying and addressing appropriate treatment needs. This provides a standardized way to communicate status which will improve both quality of treatment and efficient use of resources.
Using a standardized measure to assess psychosocial problems in children and adolescents will improve both quality of treatment and efficient use of resources. Measuring improved behavioral problems will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life.
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 2
Risk Adjusted No
Preferred Specialty mental and behavioral health
Applicable Specialties Behavioral Health, Pediatrics, Family Medicine, Psychiatry

Measure Justification

The broadband classifications of internalizing and externalizing behaviors1,2 represents one of most universally accepted and copiously cited diagnostic clusters used to characterize function of child and adolescent patient populations. This terminology has been the subject of study within a number of books and journal special issues, and the empirical robustness of these higher-order constructs received notice in the DSM-V as a useful framework for explaining common psychiatric comorbidities.3 In practice, these classifiers reflect widely applicable primary or secondary targets of most child and adolescent interventions and as such should appeal to a large swatch of mental and behavioral health practitioners. Alternative dimensional views of diagnostic classification usually include internalizing and externalizing behavior as two primary dimensions of psychosocial dysfunction,2,4-8 and through this lens, spectrums of I/E emotional and behavioral disorders routinely include oppositional defiant, conduct, attention-deficit/hyperactivity, substance use, antisocial personality, depressive, anxiety, somatic, obsessive-compulsive, and trauma and stress related disorders. With an estimated point prevalence falling somewhere between 11% and 20%, nationally,9-11 these childhood behavioral and emotional disorders are among the most common morbidities facing young people today, and these challenges extend far beyond the boundaries of behavior-specific diagnostic criteria to affect children exposed to a multitude of vulnerabilities known to increase I/E problem susceptibility like head injury,12 chronic illness,13 teratogen and toxin exposures,14,15 intellectual disabilities,16 child maltreatment,17,18 poverty,19,20 low socioeconomic levels,21 just to name a few. When untreated, I/E problems persist into adulthood,22 predict other future disorders and disabilities,23 and correspond with impaired, foundational social and emotional functioning that negatively impacts future relationships,24 physical health,25-27 mortality,28 academic achievement,29-31 work success,32 use of substances,33 and legal troubles.34,35 Because of the common co-occurrence of behavioral disorders and the broad range of vulnerabilities affecting I/E problems, an increasingly popular view suggests traditional, specialized therapeutic approaches to specific disorders will likely produce inferior quality of care when compared to treatments that focus on cross-cutting I/E targets.36-38

References
1. Achenbach TM. The classification of children’s psychiatric symptoms: A factor-analytic study. Psychological Monographs: General and Applied. 1966;80(7):1-37.
2. Achenbach TM, Edelbrock CS. The classification of child psychopathology: A review and analysis of empirical efforts. Psychological Bulletin. 1978;85(6):1275-1301.
3. Achenbach TM. Future Directions for Clinical Research, Services, and Training: Evidence-Based Assessment Across Informants, Cultures, and Dimensional Hierarchies. Journal of Clinical Child & Adolescent Psychology. 2017;46(1):159-169.
4. Krueger RF. The structure of common mental disorders. Archives of General Psychiatry. 1999;56(10):921-926.
5. Krueger RF, Caspi A, Moffitt TE, Silva PA. The structure and stability of common mental disorders (DSM-III-R): A longitudinal-epidemiological study. Journal of Abnormal Psychology. 1998;107(2):216-227.
6. Vollebergh WM, Iedema J, Bijl RV, de Graaf R, Smit F, Ormel J. The structure and stability of common mental disorders: The nemesis study. Archives of General Psychiatry. 2001;58(6):597-603.
7. Krueger RF, Markon KE. Reinterpreting Comorbidity: A Model-Based Approach to Understanding and Classifying Psychopathology. Annual Review of Clinical Psychology. 2006;2(1):111-133.
8. Kessler RC, Ormel J, Petukhova M, et al. Development of lifetime comorbidity in the world health organization world mental health surveys. Archives of General Psychiatry. 2011;68(1):90-100.
9. Weitzman C, Wegner L. Promoting Optimal Development: Screening for Behavioral and Emotional Problems. Pediatrics. 2015.
10. US Department of Health and Human Services; US Department of Education; US Department of Justice. Report of the Surgeon General’s Conference on Children’s Mental Health: A national action agenda. Washington, D.C.: US Department of Health and Human Services; 2000.
11. Costello E, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry. 2003;60(8):837-844.
12. Gerring J, Vasa R. Head injury and externalizing behavior. In: Beauchaine TP, Hinshaw SP, eds. The Oxford Handbook of Externalizing Spectrum Disorders. New York, NY: Oxford University Press; 2015:403-415.
13. Pinquart M, Shen Y. Behavior Problems in Children and Adolescents With Chronic Physical Illness: A Meta-Analysis. Journal of Pediatric Psychology. 2011;36(9):1003-1016.
14. Liu J, Liu X, Wang W, et al. Blood lead levels and childrenÕs behavioral and emotional problems: A cohort study. JAMA Pediatrics. 2014;168(8):737-745.
15. Graham D, Glass L, Mattson S. Teratogen exposure and externalizing behavior. In: Beauchaine TP, Hinshaw SP, eds. The Oxford Handbook of Externalizing Spectrum Disorders. New York, NY: Oxford University Press; 2015:416-442.
16. Pinsonneault M, Parent S, Castellanos-Ryan N, SŽguin J. Low intelligence and poor executive function as vulnerabilities to externalizing behavior. In: Beauchaine TP, Hinshaw SP, eds. The Oxford Handbook of Externalizing Spectrum Disorders. New York, NY: Oxford University Press; 2015:375-402.
17. Pears KC, Kim HK, Fisher PA. Psychosocial and cognitive functioning of children with specific profiles of maltreatment. Child Abuse & Neglect. 2008;32(10):958-971.
18. VanZomeren-Dohm A, Xu X, Thibodeau E, Cicchetti D. Child maltreatment and vulnerability to externalizing spectrum disorders. In: Beauchaine TP, Hinshaw SP, eds. The Oxford Handbook of Externalizing Spectrum Disorders. New York, NY: Oxford University Press; 2015:267-285.
19. Fitzsimons E, Goodman A, Kelly E, Smith JP. Poverty dynamics and parental mental health: Determinants of childhood mental health in the UK. Social Science & Medicine. 2017;175:43-51.
20. Mazza JRSE, Lambert J, Zunzunegui MV, Tremblay RE, Boivin M, C™tŽ SM. Early adolescence behavior problems and timing of poverty during childhood: A comparison of lifecourse models. Social Science & Medicine. 2017;177:35-42.
21. Brooks-Gunn J, Duncan GJ, Britto PR. Are socioeconomic gradients for children similar to those for adults? Achievement and health of children in the United States. In: D. K, C. H, eds. Developmental Health and the Wealth of Nations: Social, Biological, and Educational Dynamics. New York, NY: Guilford Press; 1999:94Ð124.
22. Rutter M. Relationships between mental disorders in childhood and adulthood. Acta Psychiatrica Scandinavica. 1995;91(2):73-85.
23. Copeland WE, Shanahan L, Costello E, Angold A. Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Archives of General Psychiatry. 2009;66(7):764-772.
24. Pedersen S, Vitaro F, Barker ED, Borge AIH. The Timing of Middle-Childhood Peer Rejection and Friendship: Linking Early Behavior to Early-Adolescent Adjustment. Child Development. 2007;78(4):1037-1051.
25. Appleton AA, Buka SL, McCormick MC, et al. Emotional Functioning at Age 7 Years is Associated With C-Reactive Protein in Middle Adulthood. Psychosomatic Medicine. 2011;73(4):295-303.
26. Odgers CL, Caspi A, Broadbent JM, et al. Prediction of differential adult health burden by conduct problem subtypes in males. Archives of General Psychiatry. 2007;64(4):476-484.
27. Slopen N, Kubzansky LD, Koenen KC. Internalizing and externalizing behaviors predict elevated inflammatory markers in childhood. Psychoneuroendocrinology. 2013;38(12):2854-2862.
28. Jokela M, Ferrie J, KivimŠki M. Childhood Problem Behaviors and Death by Midlife: The British National Child Development Study. Journal of the American Academy of Child & Adolescent Psychiatry. 2009;48(1):19-24.
29. Masten AS, Roisman GI, Long JD, et al. Developmental Cascades: Linking Academic Achievement and Externalizing and Internalizing Symptoms Over 20 Years. Developmental Psychology. 2005;41(5):733-746.
30. Malecki CK, Elliot SN. Children’s social behaviors as predictors of academic achievement: A longitudinal analysis. School Psychology Quarterly. 2002;17(1):1-23.
31. Duckworth K, Schoon I. Progress and attainment during primary school: the roles of literacy, numeracy and self-regulation. Longitudinal and Life Course Studies. 2010;1(3):18.
32. Kautz T, Heckman JJ, Diris R, Weel B, Borghans L. Fostering and Measuring Skills: Improving Cognitive and Non-cognitive Skills to Promote Lifetime Success. OECD Education Working Papers. 2014(110).
33. King SM, Iacono WG, McGue M. Childhood externalizing and internalizing psychopathology in the prediction of early substance use. Addiction. 2004;99(12):1548-1559.
34. Moffitt TE. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review. 1993;100(4):674-701.
35. Mannuzza S, Klein R, Konig P, Giampino T. Hyperactive boys almost grown up: Iv. criminality and its relationship to psychiatric status. Archives of General Psychiatry. 1989;46(12):1073-1079.
36. Conrod PJ, Stewart SH. A Critical Look at Dual-Focused Cognitive-Behavioral Treatments for Comorbid Substance Use and Psychiatric Disorders: Strengths, Limitations, and Future Directions. Journal of Cognitive Psychotherapy. 2005;19(3):261-284.
37. Krueger RF, Markon KE. A dimensional-spectrum model of psychopathology: Progress and opportunities. Archives of General Psychiatry. 2011;68(1):10-11.
38. Chorpita BF, Reise S, Weisz JR, Grubbs K, Becker KD, Krull JL. Evaluation of the Brief Problem Checklist: Child and caregiver interviews to measure clinical progress. Journal of Consulting and Clinical Psychology. 2010;78(4):526-536.