CCHAP Home > Newsletter Articles > Newsletter Twelve, October 2007
CCHAP Newsletter Twelve
October 2007
Screening For Postpartum Depression
Pediatrics and the Growing Latino Community in Colorado
Integrating Developmental Screening Into a Pediatric Practice
New CCHAP Program Manager
Spanish Interpretation Training for Pediatric Practices
Print Newsletter Twelve: 
Screening For Postpartum Depression
in the Mothers of your Patients
Incidence of postpartum depression and its significance
Postpartum depression (PPD) is a significant public health issue that affects approximately 12% of all mothers. In Colorado, over 7,000 women each year will develop postpartum depression or a postpartum mood disturbance, with a higher occurrence in families of lower socio-economic status (SES). Left untreated 50% of women, who develop significant postpartum depression, will still show signs of depression when their infant turns one year of age. Research shows that infants of depressed caregivers are more likely to have cognitive, linguistic, and attentional delays. Postpartum depression also is a major risk factor for children developing disruptive behavior, anxiety, depression, and severe relationship problems with their caregiver.
For a postpartum depressive mother, the episodes can lead to a mother’s personal suffering, a lack of joy in the child, missed work, possible suicide attempts, and marital discord. Research confirms that infants of depressed mothers are less likely to make health supervision visits, children are less likely to be up to date on immunizations, and are more likely to use frequent urgent and emergency care. In addition, a primary care provider’s anticipatory guidance does not promote change in parenting practices when the mother is depressed.
What is postpartum depression?
The four most common forms of distress that present clinically after the delivery are: postpartum blues, depression, anxiety, and psychosis.
- Nearly 70% of all mothers will experience some degree of postpartum blues: tearfulness, irritability, sleeplessness, impairment of concentration, isolation and headache.
- When these symptoms continue for 2 weeks post birth, and when the depressive symptoms (characterized by sadness, lack of pleasure, lack of energy, changes in sleep and appetite, excessive guilt, and poor concentration) meet criteria for major depression, it is considered to be postpartum depressive illness.
- In addition, many women also report significant anxiety during these episodes in addition to symptoms of depression. Postpartum psychosis is rare (1/750 live births), but is a medical emergency.
- Women with postpartum psychosis frequently have extreme fits of anger and agitation, are disoriented, have extreme insomnia, experience hallucinations and delusions, as well as thoughts of wanting to harm themselves or the baby.
Pediatrician’s Role
The inclusion of screening for postpartum depression has been recommended by the American Academies of Pediatrics, Family Practice, Obstetrics and Gynecology, as well as the Bright Futures Task Force. In a survey by Olson and colleagues, 57% of pediatricians believed that it was their responsibility to identify maternal depression, and an additional 27% were open to improving their skills in identification. The major barriers to identification of postpartum depression reported by the pediatrician respondents were not enough time, insufficient knowledge, and lack of experience in identifying and referring women for treatment and support. In subsequent research, this group found that surveillance by pediatricians – asking about depressive symptoms – was less effective than using a paper-based screening instrument. When a paper-based screening tool is used, the time to screen, discuss, and refer was less than 1 minute in 95% of cases, 5-10 minutes in 3%, and 10 minutes in 2% of cases. It is becoming clear that routine, brief, maternal depression screening conducted during well child visits is feasible, and that detected mothers who were willing to discuss depression respond well to referral and treatments.
Barriers to Identification and Treatment
It is important for pediatricians to do this screening since there are many barriers to women being identified and receiving treatment. First of all is social stigma and lack of public awareness. Our society believes that childbirth should be a time of excitement, when, in fact, most women are overwhelmed, lacking social support, and feeling isolated. Secondly, women with postpartum depression fall through the cracks since screening does not routinely occur at Obstetric, WIC, or other health visits. When these topics are brought up at medical visits they are frequently minimized by providers as a typical time of adjustment. Other women are afraid to mention their symptoms for fear of being hospitalized, or of having their infant removed by social services. Another barrier is lack of private mental health professional availability and community mental health resources with easily accessible programs that are tailored for the postpartum period.
Steps for Recognition and Referral
The role of the pediatric primary care provider’s office is then to 1) Screen and Identify Postpartum Depression 2) Assess Stressors and Safety of Mother and Infant, 3) Educate mother about postpartum mood disturbance, 4) Coordinate referral to other support services and 5) Review at next visit
1) Screening Tool: The Edinburgh Postnatal Depression Scale is a 10 question screening questionnaire that can be filled out by a mother in a couple of minutes and easy to score by the provider. It is designed specifically for PPD. A sample of the EPDS can be found on the Kempe Center website (www.kempe.org/ppd). On the website you can find an explanation of these PPD diagnostic tools, guidelines for administering it, scoring and referring based on the score. In addition, you can arrange for a special training session with Dr. Brian Stafford for staff and providers (see below).
2) Further assessment: Inquire about sleep, nutrition, exercise, and social supports of the mother. Explain to the mother that these are important components to being healthy and will greatly influence her treatment. Also ask the mother about thoughts of harming herself or her child. And help her to identify the people who can help her with chores and emotional support.
3) Educate: Mothers can be educated about the nature of postpartum mood disorders, the effectiveness of treatment, and impact on the infant. Handouts are available on the Kempe website (www.kempe.org/ppd).
4) Refer:
Providers can refer women with Medicaid to local mental health centers:
(clinic list available at http://d329616.pve81.pvendeavors.net/bhos/)
i) Denver County: Denver Health and Mental Health Corporation of Denver
ii) Adams County: Community Reach, Aurora Mental Health
iii) Arapahoe/Douglas County: Aurora Mental Health
iv) Jefferson County, Gilpin, Clear Creek: Jefferson Mental Health
v) Broomfield, Boulder: Boulder Mental Health
Providers can refer women with private health insurance to the Kempe Center’s Postpartum Depression Intervention Program (303-864-5845, www.kempe.org/ppd)
5) At the next well child check, the provider can reassess the mother’s distress and access to resources.
Training for your Practice
The Kempe Center’s Postpartum Depression Intervention Program offers psychiatric assessment and group therapy using an evidenced-based model that treats the mother’s depression and anxiety as well as her relationship with her infant and her partner. It is one of the few evidenced-based interventions for postpartum depression, and the only one that focuses on the mother’s relationship with her infant.
The Kempe website offers information for women, family members, and pediatricians and obstetricians, as well as the EPDS screening tool.
Kempe staff are also available to provide clinic and system trainings on postpartum depression screening. Please contact Dr. Brian Stafford at Stafford.brian@tchden.org if you or your clinic is interested.
Internet Resources:
Postpartum Support International is the primary organization for postpartum depression awareness (http://www.postpartum.net/)
The Commonwealth Fund has provided funding, and now practical tools and resources, to assist primary care providers in screening for postpartum depression.
http://www.commonwealthfund.org/usr_doc/Implementation_manual_4_16_use.pdf?section=4039
MedEdPPD (http://www.mededppd.org/) offers excellent professional training information about postpartum depression screening and research.
Pediatrics and the Growing Latino Community in Colorado
Janine Young, MD
Assistant Professor, Department of Pediatrics
University of Colorado Health Sciences Center
Denver Health and Hospitals
We live in a diverse society made up of new immigrants as well as those of us whose ancestors immigrated years ago. In the early 1900’s, new immigrants came from places like England, Scotland, Ireland, Germany, and Russia to escape religious persecution and/or poverty and to seek out better opportunities for themselves and their children.
Patients from Latin America may have an increased risk of lead exposure and intoxication. Lead paint is still used in some pottery and there are traditional folk remedies specifically used in children that have high lead concentrations (upwards of 93% lead) to treat colic, teething, gastroenteritis, and abdominal pain. These remedies include greta, azarcon, and albayalde.
With poor access to health care in their home countries, many children present to pediatricians with untreated chronic diseases and diseases in later stages than what many physicians are used to seeing. In most developing countries, families are accustomed to going to pharmacies and buying antibiotics, steroids, narcotics, and birth control over-the-counter without prescriptions. When these families come to the US, the expectations are often the same, and there are places to find these same medications without prescriptions. When asked, families will often share that they are giving their child penicillin, either orally or injected by an untrained relative, folk healer, or pharmacy owner. Families often have medications sent by relatives from Mexico to give to their children. If they bring the medication in to the visit, it is easy to do an internet search to determine what is in the medication and if it is safe to use. Often times, the medications are not needed and are over-dosed. Many women without health insurance are able to go to local pharmacies in Denver and purchase a Mexican-made medroxyprogesterone for birth control. Relatives, friends, or the pharmacy owner will inject the medication monthly for these women.
When families immigrate to the US, they often want to give their children “American food.” Many families believe that this includes the regular consumption of fast food, as well as sodas, sports drinks, and other sugar-laden beverages. Obese young children are often viewed as “healthy” and many families worry that their children are not eating enough. It is important to talk with families about dietary habits and give concrete advice as to what their children should and should not be eating (e.g. no soda in the house—only for special occasions like birthdays, etc.). Begin asking about sugary drink consumption at the 9 month well-child care visit, given that some young children are offered these drinks in bottles at this young age.
In general, immediate and extended family ties are very important to the Latino community—otherwise known as familismo. The mother, father, grandparents, aunts and uncles may come to their children’s doctor visits and all may have some say in how the child will be cared for. Grandmothers (la abuela), in particular, often have particular sway in how their grandchildren are cared for, both in what they are fed as well as herbal remedies used, and folk illness beliefs.
Caida de la Mollera (Fallen fontanelle)
Many parents have heard from their parents and grandparents that babies risk having their fontanelle fall in. When examining an infant or young child, it is useful to comment on the anterior fontanelle and its normal appearance, given that many Latino immigrant parents have heard of caida de la mollera and are concerned about it as a real medical issue. Some families believe that a fontanelle can fall if the nipple is taken from the mouth of a baby too quickly or a baby is bounced too much. Symptoms include problems feeding or swallowing, fever, diarrhea, vomiting, crying, or fussiness. Treatment, if any, includes pressing on the soft palate or feet, and teas.
Some families will present with a child who has nausea, vomiting, or diarrhea, anorexia, or abdominal pain and state that the child has empacho. Some believe that empacho is caused by eating too much or at the wrong time, consuming spoiled foods, or changing the type of formula given. Families will treat empacho with a change in diet, herbal teas, abdominal massage with oil, or powdered folk remedies with lead (Greta, azarcon, albayalde—see above). Although it is rare to encounter these folk remedies in the US, it is always important to ask families if they are treating their children with any medicines or home remedies.
Many families believe that if a jealous person looks at a child intentionally or unintentionally, a spell can be placed on that child, causing symptoms such as fever, fussiness, diarrhea, or vomiting. Many newborn babies will wear a bracelet with an amulet attached with a picture of a Mexican Catholic saint, La Virgin de Guadalupe, to protect the baby or young child from mal de ojo. These amulets are called ojo de venado (deer eye). (See photo #2).
Manzanilla (chamomile). Treats nausea, colic, anxiety, and is used as an eyewash to treat conjunctivitis (expressed breast milk is also used for conjunctivitis as well).
Ajo (garlic). Used as a cough syrup or an antibacterial.
Eucalipto (aka Vicks Vaporub). Used to treat cough, reactive airways disease, bronchiolitis, and tuberculosis.
Vertebrae from rattle snakes. Some families will have Mexican relatives send a necklace made of rattle snake vertebrae for young children to wear who are teething. The families believe that the bones prevent teething pain (see photo #3).
Caring for a diverse immigrant population is interesting, challenging, and rewarding. By attempting to understand Latino culture, beliefs, language, and practices, the quality, satisfaction, and outcomes of the clinical care that is provided can be greatly improved.
Rattle snake vertebrae to prevent teething pain
References:
Flores, G., Culture and the patient-physician relationship: achieving cultural competency in health care. J. Pediatrics. 2000;136;14-23
http://www.ethnomed.org/, University of Washington. Accessed 9/18/07
http://quickfacts.census.gov/qfd/states/08000.html. Accessed 9/18/07
www.cis.org/articles/2002/back1302.html. Center for Immigration Studies, accessed 9/18/07
There are four common types of folk practitioners in Mexico (and in Colorado). Be sure to ask if the family has seen other healers or practitioners and try to check out the treatments they have recommended. Often these alternative treatments do not cause harm. Sometimes they do.
Curanderos receive their gift from God or serve an apprenticeship. Some even prescribe over-the-counter medications. They usually treat traditional illnesses not caused by witchcraft.
Espiritistas (spiritualists) treat conditions caused by witchcraft. Amulets and prayer are a large part of the treatment. Seeing an espiritista may carry a stigma among some Hispanics
Yerberos or Jerberos use herbs, teas, and roots to prevent or treat illnesses. Patients usually purchase the herbs from a botanica, a specialist herb shop that also sells religious figurines
Sobadores treat muscle and joint problems using massage and manipulation; usually they do not have formal training
Integrating Developmental Screening
Into a Pediatric Practice
- The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool into well child visits for infants/toddlers birth to three.
- The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement standardized developmental screening into well care checks.
- Medicaid will reimburse $34.00 to providers if you implement a validated developmental screening into an EPSDT visit.
- The Colorado Chapter of the AAP supports the ABCD project in implementing enhanced developmental and behavioral screening and surveillance in pediatric practices.
- Early detection and intervention is crucial to improve outcomes. Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test.
- What should providers do? Use a new, brief, accurate, standardized, time-efficient tool for developmental screening. The most time-efficient tool is one in which the parent completes a questionnaire.
- To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
- Currently in Colorado, based on December 1, 2006 Child Count Data, only 1.9% of the birth to three population is being identified as eligible for early intervention services. Colorado’s goal by 2010 is 2.5 %, which is the national average for identifying birth to three year olds as eligible for early intervention
- What are providers saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tool:
- It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
- In many instances, it reduces the length of the visit.
- It helps providers concentrate on what are the concerns/priorities of the caregivers.
- It reduces the doorknob concerns as you are walking out the door of a well care visit.
- It improves patient satisfaction and positive parenting practices.
- It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
- Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices in the implementation of a standardized tool such as the ASQ or PEDS. Support will also be given to front/back office staff on how to implement the use of a standardized developmental screening tool into the current office work flow.
For more information, please contact:
Eileen Auer Bennett
720-333-1351
ileanben@yahoo.com
The Ages & Stages Questionnaire (ASQ)
elements and practical application. Health care providers
have identified the advantages to include:
- Parent completed—Parents are partners in their child’s
assessment and intervention activities. - Serves as a talking guide with parents identifying a
child’s strengths as well as things the child is not
doing yet. - Practical—Scoring takes 2–3 minutes and can be done
by paraprofessionals. - Cost-efficient—May be photocopied repeatedly.
- Scoring is simple—Only three responses:
- Sometimes, occasional or emerging response from
child = 5 points - Yes, child performs specified behavior = 10 points
- Not Yet = 0 points
If the child’s total score falls in a shaded area of the bar
graph for any developmental area, further diagnostic
assessment is recommended.
Visit http://www.brookespublishing.com/ to view and order the
ASQ tool online.
The Parents’ Evaluation of Developmental
Status (PEDS)
a pediatric surveillance program. Provider feedback has
been positive. “The PEDS is nice because physicians value
knowing the issues parents want to address before going
into the room.”
Below are other advantages outlined in an article by
Frances Glascoe, PhD, Associate Professor, Division of
Child Development, Vanderbilt University School of
Medicine:
- Developed out of four cross-validation studies on a
nationally representative sample of families. - Uses parent concerns or judgments about the child’s
development and behavioral status. - Easy to score—two minutes to elicit and interpret.
- Enables health care providers to determine the need to
refer and where.
Visit http://www.pedstest.com/ to view and order the PEDS tool online.
CCHAP is changing:
We have a NEW program manager
She has an open door policy and would love to hear from you, her direct number is 720-777-6309 and her email address is ells.christina@tchden.org
Please come and welcome Christina to CCHAP at the Practice Managers Meeting on October 16th, 2007 at noon here at the new Children's Hospital!!!!
12 Noon – 1pm
4th Floor – The Children’s Hospital
at 13123 E.16th Avenue, Aurora 80045
(Please allow 15 minutes for badging & bring your driver’s license)
Spanish Interpretation Training for Pediatric Practices
Medical (pediatric) terminology
Subtle differences in the two languages in word selection and grammar
Culturally appropriate communication skills
Professionalism and etiquette of interpretation
Confidentiality and HIPPA issues
Name of student:
Job title:
Pediatric practice name:
Work phone number:
Home phone number:
Is your first language English or Spanish?
If Spanish is your second language, how long have you been speaking it?
What time is your usual lunch hour?
What is your goal in enrolling in this class?
Price: $20 per session.
After your registration and start date is confirmed, please send a check for $120,
payable to International Language Services
12572 West Brandt Place, Littleton CO 80127.
Contents:
Screening For Postpartum Depression
Pediatrics and the Growing Latino Community in Colorado
Integrating Developmental Screening Into a Pediatric Practice
New CCHAP Program Manager
Spanish Interpretation Training for Pediatric Practices
CCHAP Home > Newsletter Articles > Newsletter Twelve, October 2007
