Download Action Period #1

PSP Child and 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.
www.pspbc.ca
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Faculty/Presenter Disclosure
Speaker’s Name: 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
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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].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
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CYMH Module Facilitators
GP Champion
School Psychologist
PSP Coordinators
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Session Opening
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
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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
AP1
LS2
AP2
LS3
AP3
LS4
Ongoing
Support
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Here in BC
Prevalence % for Children & Youth under 25 yo
Estimated
numbers
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
0.1%
0.1%
900
900
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Module Aim
What are we trying to accomplish?
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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
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How do we aim to do this?
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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
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Child and Adolescent Health
Global Comparative Burden of Illness for Mental Illness
Table: World: DALYS in 2000 attributable to selected causes by age
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Myths About Treatment
 Medications are detrimental
 Difficult to treat
 Vitamins and rest are effect treatments
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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
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Knowing Your Limits
Image ID: 898215 stock.xchng
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Parenting Overview

Love and affection
 Quality individual time
 Affection, words & actions
 Stress
management
 Strong relationships
 Spouse/partner & friends
 Good modeling of social skills

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Developmental Transitions
 Adolescence to Adulthood
 Primary caregiver should address issues as they
change over the life span
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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
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Abusive Experiences
 Abusive experiences
increase risk of
behavioral and
emotional disorder
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Engaging the School
 Important to engage the
school
 Mental disorders impact
all aspects of functioning
 Know how child is doing
academically and
socially
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Engaging the School
 Ensure appropriate
confidentiality and
consent
 Be available for contact
by school
 Educate school on use of
forms and tools
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Table Discussion: Roles
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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?
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Suicide Risk Assessment
 If Depression is suspected:
 Pay particular attention to risk:
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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
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Assessing Suicide Risk
 Ask Questions
 Understand what the child means by ‘dead’
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Suicide Risk Assessment
 Unrecognized/untreated mental illness is strong
risk factor
 Suicide increases with several factors:
www.Dreamstime.com ID:1195260
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High risk for suicide is a
MEDICAL EMERGENCY!
 Assess at baseline & throughout treatment
 Immediately contact CYMH worker as per
protocol
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KADS-6
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TASR-A
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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
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Safety & Contingency Planning
 Emergency Contact Cards
“wallet card”
 Rapid Health Provider
Availability
 Help Phone/Crisis Hot Line
 Suicide Contracts – not
useful
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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
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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!
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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
•
•
•
•
•
•
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
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Initial Screening
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?
www.freedigitalphotos.net by renjith krishnan
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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
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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
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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
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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)?
› 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
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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
www.freedigitalphotos.net by Boaz Yiftach
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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
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Kutcher Adolescent
Depression Scale
(KADS)
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Use of SCARED in Assessment
Anxiety disorder is suspected:
if score of 25 or higher
5454
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SNAP-IV
Teacher and
Parent 18-item
Rating Scale
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Psychotherapeutic Support
& Non-Specific Interventions
Psychotherapeutic Support
www.freedigitalphotos.net by Photostock
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Non-Specific Interventions








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Exercise
Sleep
Consistent Daily Routine
Positive Social Contact
Healthy Nutrition
Music & Movement
Bright Light
Avoid Drugs (including
recreational drugs)
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Sleep Assessment
www.freedigitalphotos.net by Graur Codrin
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Kelty Mental Health Resource Centre
 www.keltymentalhealth.ca
 1-800-665-1822 or Vancouver 604-875-2084
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Referral Flags
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
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Referral Flags
› Urgent Referral (treatment may be already
initiated)
› Usual Referral
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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”
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Action Planning
Module Structure
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Data Collection Sheet
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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
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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
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Key Resources
 Child and Youth Action Planning Form
 PSP website: http://www.pspbc.ca
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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
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When in doubt – Ask the Experts!
Action Period #1
How Can PSP Support You?
In-person follow up visits
Provide ongoing informational resources
Provide linkages to community resources
Algorithm support
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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
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