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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