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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 Please complete your Hollander Survey before we begin There will be a prize draw for all completed entries 2 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 3 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]. 4 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document 5 CYMH Module Facilitators GP Champion School Psychologist PSP Coordinators 6 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 8 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 9 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 10 Module Aim What are we trying to accomplish? 11 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 12 How do we aim to do this? 13 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 15 16 Child and Adolescent Health Global Comparative Burden of Illness for Mental Illness Table: World: DALYS in 2000 attributable to selected causes by age 17 Myths About Treatment Medications are detrimental Difficult to treat Vitamins and rest are effect treatments 18 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 19 Knowing Your Limits Image ID: 898215 stock.xchng 20 Parenting Overview Love and affection Quality individual time Affection, words & actions Stress management Strong relationships Spouse/partner & friends Good modeling of social skills 21 ID 820368 stockxchng Developmental Transitions Adolescence to Adulthood Primary caregiver should address issues as they change over the life span 22 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 23 Abusive Experiences Abusive experiences increase risk of behavioral and emotional disorder 24 Engaging the School Important to engage the school Mental disorders impact all aspects of functioning Know how child is doing academically and socially 25 Engaging the School Ensure appropriate confidentiality and consent Be available for contact by school Educate school on use of forms and tools 26 Table Discussion: Roles 27 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? 28 29 Suicide Risk Assessment If Depression is suspected: Pay particular attention to risk: 30 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 31 Assessing Suicide Risk Ask Questions Understand what the child means by ‘dead’ 32 Suicide Risk Assessment Unrecognized/untreated mental illness is strong risk factor Suicide increases with several factors: www.Dreamstime.com ID:1195260 33 High risk for suicide is a MEDICAL EMERGENCY! Assess at baseline & throughout treatment Immediately contact CYMH worker as per protocol 34 KADS-6 35 TASR-A 36 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 37 Safety & Contingency Planning Emergency Contact Cards “wallet card” Rapid Health Provider Availability Help Phone/Crisis Hot Line Suicide Contracts – not useful 39 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 40 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! 41 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 43 44 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 46 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 47 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 48 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 49 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 50 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 51 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 52 Kutcher Adolescent Depression Scale (KADS) 53 Use of SCARED in Assessment Anxiety disorder is suspected: if score of 25 or higher 5454 54 SNAP-IV Teacher and Parent 18-item Rating Scale 55 Psychotherapeutic Support & Non-Specific Interventions Psychotherapeutic Support www.freedigitalphotos.net by Photostock 57 Non-Specific Interventions www.freedigitalphotos.net by Photostock Exercise Sleep Consistent Daily Routine Positive Social Contact Healthy Nutrition Music & Movement Bright Light Avoid Drugs (including recreational drugs) 58 Sleep Assessment www.freedigitalphotos.net by Graur Codrin 59 Kelty Mental Health Resource Centre www.keltymentalhealth.ca 1-800-665-1822 or Vancouver 604-875-2084 60 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 62 ID 837573 stockxchng Referral Flags › Urgent Referral (treatment may be already initiated) › Usual Referral 63 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” 64 Action Planning Module Structure 66 Data Collection Sheet 67 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 68 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 69 Key Resources Child and Youth Action Planning Form PSP website: http://www.pspbc.ca 70 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 71 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 73 73 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 74