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PSP Child & Youth Mental Health
Learning Session 1
© 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher. Health educators and health
providers are permitted to use this publication for non-commercial educational purposes only. No part of
this publication may be modified, adapted, used for commercial or non-educational purposes without the
express written consent of the BCMA and Dr. Kutcher.
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name:
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
3
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
6
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
7
$1,540.18
$160.00
Please complete your
Hollander Survey
before we begin
There will be a prize draw for all
completed entries
8
CYMH Module Facilitators
GP Champion
School Psychologist
PSP Coordinators
9
Session Opening
10
Agenda
 What we are trying to achieve and our approach
 Patient/Family Voice
 Framework:
› Lifespan
› Suicide Risk
› Child and Youth Mental Health Algorithm
› Overall Framework
 Planning for the Action Period
11
Practice Support Program (PSP)
 Learning Sessions: peer-led learning, team based
approach
 Action Periods: periods between Learning
Sessions; work with PSP Coordinator to implement
changes into practice
LS1
12
AP1
LS2
AP2
LS3
AP3
LS4
Ongoing
Support
Here in BC
Prevalence % for Children & Youth under 25 yo
Any anxiety disorder
6.5%
60,900
ADHD
3.3%
30,900
Conduct Disorder
3.3%
30,900
Any depressive disorder
2.1%
19,700
Substance abuse
0.8%
7,500
Pervasive developmental disorder
0.3%
2,800
Obsessive compulsive disorder
0.2%
1,900
Schizophrenia
0.1%
900
Tourette’s
0.1%
900
Eating disorders
Bipolar disorders
13
Estimated
numbers
0.1%
0.1%
900
900
Module Aim
What are we trying to accomplish?
14
This PSP Module is NOT
 A program to increase labeling of and prescribing
for children and youth
 Intended to make you a mini child psychiatrist
 Designed to make more work in your already too
busy day
15
How do we aim to do this?
16
Life Span Framework
 …70% of mental disorders
onset (diagnostic) prior to
age 25 years
 About 80% of mental
disorders in young people
can be effectively treated
in primary care
18
19
Child and Adolescent Health
Global Comparative Burden of Illness for Mental Illness
Table: World: DALYS in 2000 attributable to selected causes by age
20
Myths About Treatment
 Medications are detrimental
 Difficult to treat
 Vitamins and rest are effect treatments
21
Feeling at Home
 Office atmosphere
› Family feels safe and supported
› Space for private discussions
› Train reception and support staff
 About mental disorders
 Supportive techniques for calming
and welcoming
 Mental Health First Aid – Children and Youth
› Combat misperceptions and stigma
Freedigitalphotos.net Salvatore Vuono
22
Knowing Your Limits
Image ID: 898215 stock.xchng
23
Parenting Overview

Love and affection
 Quality individual time
 Affection, words & actions
 Stress
management
 Strong relationships
 Spouse/partner & friends
 Good modeling of social skills

24
ID 820368 stockxchng
Developmental Transitions
 Adolescence to Adulthood
 Primary caregiver should address issues as they
change over the life span
25
Engaging the Adolescent
Be Yourself
Keep an open mind
Do not try to act cool,
or hip
Do not try to act like a
teenager
Be real, but not
judgmental
26
Abusive Experiences
 Abusive experiences
increase risk of
behavioral and
emotional disorder
27
Engaging the School
 Important to engage the
school
 Mental disorders impact
all aspects of functioning
 Know how child is doing
academically and
socially
28
Engaging the School
 Ensure appropriate
confidentiality and
consent
 Be available for contact
by school
 Educate school on use of
forms and tools
29
Table Discussion: Roles
30
Role Discussion
 Please introduce yourself to the team, what is your
name, role in caring for children and youth with mental
health concerns, and where do you work? (5min)
 What motivated you to be involved in this module?
(10min)
 What are you hoping the team can achieve for patients
through this module? (10min)
For those who have already had intro conversation
previously:
 What topics or areas of practice are you hoping to get
more information about through your participation in this
module?
 Who is the overall care team leader?
31
32
Suicide Risk Assessment
 If Depression is suspected:
 Pay particular attention to risk:
33
Assessing Suicide Risk
 Suicide in children is rare
 Gently inquire with child if:
› Family history of suicide
› Parent/child reports of self harm behaviors
› Parent/child reports of substantial depressive
symptoms
› Inquire in age appropriate manner
34
Assessing Suicide Risk
 Ask Questions
 Understand what the child means by ‘dead’
35
Suicide Risk Assessment
 Unrecognized/untreated mental illness is strong
risk factor
 Suicide increases with several factors:
36
www.Dreamstime.com ID:1195260
High risk for suicide is a
MEDICAL EMERGENCY!
 Assess at baseline & throughout treatment
 Immediately contact CYMH worker as per
protocol
37
KADS-6
38
TASR-A
39
Suicide Ideation
HOPELESSNESS INCREASES RISK
remember not everyone who has a diagnosis of
anxiety or depression feels hopeless.
ALWAYS ask about a suicide plan
If there is suicide ideation or hopelessness
40
Safety & Contingency Planning
41
 Emergency Contact Cards
“wallet card”
 Rapid Health Provider
Availability
 Help Phone/Crisis Hot Line
 Suicide Contracts – not
useful
42
Safety Card
Safety Card- Emergency Contact Number
• Dr. (xxxxxxxx) number and email: 604-xxx-xxxx [email protected]
• Emergency room 604-xxx-xxxx
• Vancouver Child and Youth Mental Health Referral Line: 604-675-3895
• Helpline for children: Toll-Free in BC (no area code needed) 310.1234
• Crisis Intervention and Suicide Prevention Centre of BC
Lower Mainland 604.872.3311
Toll Free 1.866.661.3311
• SAFER (Suicide Attempt Counselling Service) 604-675-3985
• Vancouver Island Crisis Line 1-888-494-3888
43
Table Discussion: Suicide Risk Assessment
 Have you used the TASR-A with any children or
youth before?
 How would you use it?
 How can you involve the family and others for
support?
If Time Allows!
44
Framework
www.pspbc.ca
Core Tools Framework
Screening Tools
Primary Assessment Tool
Secondary Assessment Tools
•
•
•
•
•
•
Child and Youth Mental
Health (CYMH) Screening
Questions
CRAFFT
Clinical Global Impression
Scale (CGI)
Depression: KADS6, TASR-A
Anxiety: SCARED
ADHD: SNAP-IV 18
Treatment and Management Tools
•
•
•
•
•
46
•
Mood Enhancing Prescription/Worry
Reducing Prescription
Teen Functional Assessment (TeFA)/
Child Functional Assessment (CFA)
CBIS
Medication Algorithms
Side effects Scales (Kutcher Side Effect Scale for
ADHD Medication (KSES-A), Short Chehil-Kutcher
Side (sCKS) Effects Scale
Referral
•
Ministry of Children and Family
Development – Child and Youth
Mental Health Services
•
Psychiatrists
•
Pediatricians
•
RACE
•
Strongest Families BC
•
Kelty Resource Centre
47
Initial Screening
48
Mental Health Screening Q’s
 Historical Factors
 Parental history of
mental disorder
 Family history of
suicide
 Childhood diagnosis
of other disorders?
 Other recent
significant events at
school, home or
social life?
49
www.freedigitalphotos.net by renjith krishnan
Mental Health Screening Q’s
 Marked change in usual:
› Emotions
› Behavior
› Cognition, or
› Functioning
 Based on youth or parent report
www.freedigitalphotos.net freedigital Hooded Person by Ambro
One or more of the above answered as YES
child or youth is in a high risk group.
The more YES answers, the higher the risk
50
Mental Health Screening Q’s
1. Over the past few weeks have you been having
difficulties with your feelings, such as feeling
sad, blah or down most of the time?
› If YES – consider a depressive disorder
› Apply the KADS evaluation
51
Mental Health Screening Q’s
2. Over the past few weeks have you been feeling
anxious, worried, very upset or are you having
panic attacks?
› If YES – consider an anxiety disorder
› Apply the SCARED evaluation
› Proceed to the Identification, Diagnosis and
Treatment of Child and Adolescent Anxiety
Disorders Module
52
Mental Health Screening Q’s
3. Overall, do you have problems
concentrating, keeping your mind on
things or do you forget things
easily (to the point of others
noticing and commenting)?
›
›
›
53
If YES – consider ADHD
Apply the SNAP-IV evaluation
Proceed to the Identification, Diagnosis
and Treatment of the Child and
Adolescent ADHD Module
www.freedigitalphotos.net by Boaz Yiftach
Mental Health Screening Q’s
4. There has been a marked change in
usual emotions, behaviour, cognition
or functioning (based on either
youth or parent report)
 If YES – probe further to determine if
difficulties are on-going or transitory.
 Consistent behaviour problems at home
and/or school may warrant referral to
Confident Parents/Thriving Kids
54
www.freedigitalphotos.net by Boaz Yiftach
Next Steps …
 Positive for Depression + Anxiety or ADHD
› Apply KADS and protocol for Depression
› After treatment, review for presence of continued
Anxiety Disorder or ADHD
 If continues positive for Anxiety Disorder
› Refer to specialty mental health services
 If continues positive for ADHD
› Follow the protocol in the ADHD toolkit, OR
› Refer to specialty mental health services
55
Kutcher Adolescent
Depression Scale
(KADS)
56
Use of SCARED in Assessment
Anxiety disorder is suspected:
if score of 25 or higher
57
57
57
SNAP-IV
Teacher and
Parent 18-item
Rating Scale
58
Another Way to Monitor Treatment Outcomes
Some clinicians like to use
the
Clinical Global
Impression Scale (CGI)
to monitor outcomes.
This scale can be used in
evaluating treatment for
any mental disorder.
59
Clinical Global Impression Improvement Scale
(CGI)
Compare how much the patient has improved
or worsened relative to their baseline state at
the beginning of medication treatment.
It may be useful to record CGI score at every
mental health visit.
0 = Not Assessed
1 = Very Much Improved
2 = Much Improved
3 = Minimally Improved
4 = No Change
5 = Minimally Worse
6 = Much Worse
7 = Very Much Worse
60
Psychotherapeutic Support
& Non-Specific Interventions
61
Psychotherapeutic Support
62
www.freedigitalphotos.net by Photostock
Non-Specific Interventions








63
www.freedigitalphotos.net by Photostock
Exercise
Sleep
Consistent Daily Routine
Positive Social Contact
Healthy Nutrition
Music & Movement
Bright Light
Avoid Drugs (including
recreational drugs)
Sleep Assessment
www.freedigitalphotos.net by Graur Codrin
64
Kelty Mental Health Resource Centre
 www.keltymentalhealth.ca
 1-800-665-1822 or Vancouver 604-875-2084
65
Referral Flags
66
Referral Flags Refer at 3 different points
•
Emergency Referral
(prior to treatment
initiation) from within
hospital setting - CYMH
> Suicide ideation with
intent or plan
> Major depressive episode
with psychosis
> Delusions or
hallucinations
ID 837573 stockxchng
67
Referral Flags
› Urgent Referral (treatment may be already
initiated)
› Usual Referral
68
Abuse or Neglect Concerns
 Helpline for Children
› 310-1234 (free – no area code required)
› 24 hours/7 days
› Do not have to give your name
 Immediate danger
› 9-1-1 or local police
 Resources
› Ministry of Children and Family Development
› www.mcf.gov.bc.ca/child_protection
› See “Handbook for Action on Child Abuse and Neglect”
69
Action Planning
70
Module Structure
71
Data Collection Sheet
72
Action Period Requirements: Example Depression
 Screening using Mental Health Screening Questions and
assessment with KADS-6, SNAP-IV or SCARED (4 patients)
 Created a registry including child and youth with positive
screen/diagnosis
 Provided psychotherapeutic treatment to 2 patients
 Provided pharmaco-therapeutic treatment to patients, as required
 Retested KADs on subsequent mental health visits for patients
with a positive screen/diagnosis of Depression
 Recorded CGI scores at every patient visit
73
Changes to try
 Identification and screening of children and youth
 Creation of a registry
 Treatment processes
 Team-based care - GP’s, Schools, other care
providers
 Linking with community programs and supports
74
Key Resources
 Child and Youth Action Planning Form
 PSP website: http://www.pspbc.ca
75
Action Period Planning – Team Activity
 With your community team (e.g. GP, MOA,
School Counselor, Mental Health Clinicians…),
discuss what changes you will test in the action
period
 Fill out the action planning form
 Write the PLAN for your first Plan, Do, Study, Act
cycle
76
When in doubt – Ask the Experts!
77
Action Period #1
How Can PSP Support You?
In-person follow up visits
Provide ongoing informational resources
Provide linkages to community resources
Algorithm support
78
A Few Last Things….
 PSP Learning Session
Evaluation – everyone
BLUE sheet
 Invoice Form - GPs and
MOAs – Collect as you
leave
 AP1 Sheet – please
complete and submit with your
evaluation form to registration
as you leave
79
THANK YOU