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Psychiatric Interview Externalizing Disorders 7/16/2013 Cognitive behavioral therapy Clinical hypnosis: level two Sheree Shafer FNP-BC, PMNCNS-BC, DNP ADOS (Autism Diagnostic Observation Schedule) Child First (Forensic interview for child and adolescent sexual abuse) Dialectical behavioral therapy interventions Treatment for 700-800 patients per year (two NP’s) Research: increasing primary care nurse Comprehensive evaluation practitioner knowledge, comfort, and Facilitate referrals as needed Provide both pharmacotherapy and nonpharmacotherapy practice for pediatric patients with ADHD, Therapist for 0-5 population, liaison with BSU for children and mothers with post partum depression depression, and/ or anxiety disorders Grant for drug and alcohol therapist, specializes in Served as a CBT therapist and blind evaluator adolescent care (intake completed at our office within one week of referral) for a quasi experimental study measuring the Collaborating psychiatrist on site monthly MA dedicated to program effectiveness of 6-8 CBT sessions provided Formalized referral process within primary care versus treatment as usual Strong relationship with school psychologists Formalized process for communication with local school Program evaluation districts At the current rate of service utilization, approximately 12, 624 child and adolescent psychiatrists are needed. The number of available psychiatrists through 2020 is projected as 8,312 (AACAP, 2009). 1 7/16/2013 80% of children and adolescents respond to CONVENTIONAL MENTAL HEATH INTEGRATED MODEL OF CARE current evidence based treatment Call for phone discussion of need Call for discussion of need, Call back for an intake intake information completed interventions for ADHD ,anxiety, and Intake within 2 weeks Reviewed and call back within 48 depressive disorders (American Academy of Staffing within 2 weeks hours Assignment within 2 weeks Diagnostic and treatment Children and Adolescent Psychiary,2007; Psychiatric evaluation may be evaluation within 2 weeks. months Treatment begins American Academy of Pediatrics, 2001) Med management, Copy forwarded to PCP of choice 70% medication management casemanager, therapist are all Therapist, casemanager, and different people med management same person Psychiatric “McMental Health” Interview Barriers “ My child is Time irritable” Reimbursement ODD Overlap of Depression symptoms across Anxiety diagnostic Bipolar D/O categories Relational problem Expertise Drugs/ Alcohol Lack of mental Abuse health medical Anemia providers Evaluation is ongoing Comprehensive evaluation Developmental Disorders . There is no such thing as an “ADHD evaluation” Expectations Developmental . Treat according to level of comfort and Aspects knowledge . Recognize disorders Comorbidity is the standard Detailed documentation Patience External Expect diagnosis, medication use to be Variables: family / challenged peer issues….. 2 7/16/2013 Erikson Relationship Piaget Comfort with place, staff Neurobiology Decreased stigma Change theory Ongoing care Behavioral development, intervention Initial interview is also a diagnostic interview Family development Chronic care model of care MA in a different role Designate a staff member to manage forms Standards of practice Chronic care model . AACAP Educate: purpose of visits . AAP Establish mental health time slots . APA Manage OBTW’s . Texas Algorithm Spread sheets to track visits, follow up appt’s . GLAD –PC Designated staff member calls and documents attempts to continue engagement Establish policies for medication Mental health care is respected and treated management as all other disorders Staff education Primary care providers trained and . Refills competent . Safety plan management . Mental health evaluation . Follow up appointments . Comprehensive treatment of common mental . Forms needed health disorders Referral information . Member of the mental health treatment team . Excel in the treatment of somatic disorders 3 7/16/2013 Take a chance?? Make a difference Treatment P s y c h o Know the evidence!!!! Why not to ask why???? Open ended questions Hear a theme three or more times, may interpret DO NOT GIVE ADVICE!!!!!! Relationship begins with the first interaction Information gathered for referral Suggest designated staff member Determine office appointment or referral Referral information completed . Have a list of providers in the area Instructed on needs for first visit Office . Release of information for school (school concerns), other providers . Forms needed . Must be accompanied by legal guardian who . Release of information for schools if needed or knows the child very well, can make health care other providers decisions . Schedule (preferably within two weeks) . 15 minutes early to complete behavioral scales 4 7/16/2013 Appointment Foundation for care . Explain realistic expectations of treatment, DSM diagnosis policies Treatment decisions . Establish concerns, diagnosis, goals and discuss Shapes patient-provider relationship with family (profound impact on treatment outcomes) . Establish realistic expectations Include behavioral scales . Establish time to evaluate progress toward goals Introduction Not a time to discuss bias, possible treatment . Self options Avoid discussing whether or not the child will . Reason for visit talk to you alone . Need for asking many questions (basis for Note parent-child interaction diagnosis, ask at all interviews) Reflect emotional state; “this is difficult” . Will be seen together and alone (from age 5 years) Accept defense mechanisms: humor, avoidance, rationalization, displacement . Establish confidentiality Initial time together: brief social history . Will reflect information to assure understanding Negative interaction (parent and child: separate . Will document; information is very important quickly) Brief social history (from patient and caregiver) Invite participation, allow patient to make . Who all lives in your home? Duration decisions when possible: I will talk to each of . School; grades A’s & B’s, B-C’s Usual or a change you separately. Generally I speak with the . Favorite class, relationship with teachers, peers parent first…is this alright with you . Home: what do you like to do . Activities Younger child: spends time with MA . Few or a lot of friends. Usual. Changes Be at eye level or lower . Begin a timeline Be relaxed . Note source and reliability of informants Open ended questions…tell me . Younger children: draw a picture of house and family about…please tell me more about 5 7/16/2013 Evaluate according to symptoms, not Evaluate for all diagnosis associated with the assumed diagnosis symptoms by going through the DSM criteria Example: Irritability is to mental health as fever is to . Parent: “I think my child has ADHD …depression” physical care . Response: tell me about this; what behaviors or Inattention is associated with depression and changes are leading you to… anxiety as well as ADHD (internalizing . Reflect information disorders are not well recognized or articulated by children) “My child is irritable” Avoid processing stressors, rationalizing . Assist with clarification: once a week, a day issues, premature end to history (can meet ..begin before or after Christmas criteria for more than one diagnosis) . Note differences during the day but avoid rationalization, assumptions Example: long history of inattention and . Same, better, worse disorganization compensated adequately . What helps, hurts during elementary school, now with severe . When do you remember being happy, note strengths, dysfunction accompanied by amotivation and positives irritability, fatigue, withdrawal, and . Timeline!!!!! (assists with differential diagnosis, symptom severity, progression, and developmental anhedonia concerns) Reflect information I ask you some questions about your home and Assess ego strength family…now I have a some more questions . HEADSSSSA (S=sleep, sex, suicide, safety; A=appetite . Adaptability including caffeine use) ▪ How do you deal with strong feelings . House rules ▪ How do you solve problems . What happens if you break a rule, parent follow through . Chores, responsibility . Resourcefulness . Family activities ▪ Who do you go to with problems (adult) . Note ownership of responsibility (tell me your role…) . Self esteem . Note insight . Check if observed interaction is the standard ▪ Tell me good things about you . Reflect information ▪ Tell me things you would change 6 7/16/2013 Family role (value) Review behavioral scale responses that are Who are you, beliefs significant / clarify discrepancies How would your family describe you Reflect to the child what will be shared with How would your friends describe you parent, agree on information (confidentiality) Ask for current knowledge of tentative disorder(s), any bias but do not yet engage on treatment plan Treatment Preschool Effectiveness Elementary (primary and secondary) Adequate trial Early teens Mild to late teens Depression: SIGECAPS Diagnosis and behaviors Anxiety: general, panic, separation, social, and OCD “Does your child remind you of anyone else in PTSD Psychosis the family?” . See or hear things that are not there How was school for parents? . Thought broadcasting, mind control, paranoia . Reality testing Attempt to evaluate for behaviors, symptoms ADHD, ODD, CD before a drug or alcohol disorder Eating disorder symptoms (sense of self, ego) Somatic symptoms (dizziness, fainting, fatigue, Cardiac
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