7/16/2013

 Cognitive behavioral  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 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 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 , 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 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  symptoms (sense of self, ego)  Somatic symptoms (dizziness, fainting, fatigue,  Cardiac history headaches, abdominal pain, toileting, staring episodes,  History of suicide snoring)  Reflect information  Remain nonjudgmental  Anything else you would like tell me

7 7/16/2013

 Appearance  Perceptual disturbances  Motor activity (include impulsivity)  Cognition*  Speech  Insight: displacement, projection, other  Mood / Affect (sad, constricted, blunted, defense mechanisms; or insightful into…. appropriateness)  Judgment: risk taker, impulsivity: act before  Thought content: concrete, focused on narrow area of interest, literal interpretation, able to think hopeless or helpless theme  Thought process: derailment, tracks, perseverative

 Targeted / cardiac / endocrine / neuro  Reflect information that leads to diagnosis,  Updated WCC what questions remain  Vitals and plot height and weight  AIMS* (abnormal involuntary movement scale)

 Psycho education . Praise participation, acknowledge any use of defense mechanisms as means to deal with difficult issues, . Diagnosis situation . Rationale . Role with resistance, develop discrepancies, be empathetic (motivational interviewing) . Neurobiological changes with diagnosis, impact . Discuss usual treatment course (time, frequency of visits) of development . Develop plan with family and patient . Evidence based treatment options (use guidelines . Plan may be to give information to read, websites and NIMH studies), relate to neurobiology then meet again . Schedule for return visit (even if referring to another professional; active monitoring) . Patient registry

8 7/16/2013

 American Academy of Child and Adolescent (2007). Practice parameter for the  Journal of American Medical Association (2002 Oct 9) 288(14):1740-8, assessment of and treatment of children and adolescents with attention- http://help4adhd.org/en/about/causes/pathophysiology deficit/hyperactivity disorder. Journal of American Academy Child and Adolescent Psychiatry.  Mental Health Report: A Report of the Surgeon General. (2008). Available on line at 46:7 www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html  American Academy of Pediatrics (2011) Enhancing pediatric mental health care: strategies  Saddock, BJ; Saddock. VA; Ruiz, PR. (2009). Comprehensive Textbook of Psychiatry, 9th ed. for preparing a primary care practice.  Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., Laraque, D. (2007). Guidelines for http://pediatrics.aappublications.org/content/125/Supplement_3/S87.full.html adolescent depression in primary care (GLAD-PC): Identification, assessment, and initial  American Academy of Pediatrics (2009). The future of pediatrics: mental health management. Pediatrics, 120, 1299-1312. competencies for pediatric primary care.  Wheeler, K. (2008). for the Advanced Practice Psychiatric Nurse . Mosby. http://www.pediatrics.org/cgi/content/full/124/1/410 Missouri.  American Family (2009). Practice guidelines. http://www.aafp.org/afp/2009/0515/p905.html  American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

9