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Managing Behavioral Problems and Substance Use Mental Health Learning Collaborative Learning Session April 10, 2015 Speakers: Bhavin Dave, MD, Children’s National Health System Katherine Hobbs Knutson, MD, MPH Children’s National Health System Nicole Martino, LICSW, DC Department of Behavioral Health Accreditation Accreditation The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The George Washington University School of Medicine and Health Sciences designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Instructions for Obtaining Credit At the end of this webinar, you will receive an email for completing the online course evaluation. Your certificate of credit will be available immediately after you complete the evaluation. Disclosure In accordance with the Accreditation Council for Continuing Medical Education's Standards for Commercial Support, The George Washington University Office of Continuing Education in the Health Professions (CEHP) requires that all individuals involved in the development and presentation of CME activity content disclose any relevant financial relationships with commercial interest(s). CEHP identifies and resolves all conflicts of interest prior to an individual’s participation in an educational activity. The following faculty, planners, and staff report that they have no relevant financial relationships with commercial interest(s): • • • • • • Bhavin Dave (Speaker) Katherine Hobbs Knutson (Speaker) Nicole Martino (Speaker) Mark Weissman, MD (Course Director) Tamara John, MPH (Staff Planner) Leticia Hall-Salam (Staff) Commercial Support: This activity received no support from a commercial interest. General Information Release Date: March 25, 2014 Termination Date: March 25, 2014 Hardware/Software Requirements PC • • • • • • Contact Information Tamara John Ph: (202)476-5781 Em: [email protected] Microsoft Windows 2000 SE or above. Internet Explorer (v5.5 or greater), or Firefox Flash Player Plug-in (9.0 or later) Check your version here. Policy on Privacy & Confidentiality Sound Card & Speakers 800 x 600 Minimum Monitor Resolution (1024 x 768 Recommended) Adobe Acrobat Reader* http://www.gwu.edu/privacy-policy MAC • MAC OS 10.2.8 Copyright • Safari or Firefox • Flash Player Plug-in (9.0 or later) Check your version here. http://www.gwu.edu/copyright • Sound Card & Speakers • 800 x 600 Minimum Monitor Resolution (1024 x 768 Recommended) • Adobe Acrobat Reader* • Internet Explorer is not supported on the Macintosh. * Required to view printable (PDF) version of the lesson. Managing Behavior Problems in Youth Bhavin Dave, MD Assistant ProfessorDepartment of Psychiatry and Behavioral Sciences Associate Director-Infant & Toddler Mental Health Program Children’s National Health System 5 Assess • Evaluate for any mental health diagnoses • Rule out any medical issues • Assess for any psychosocial stressors – At home? – At school? Managing Behaviors • • • • Treat underlying psychiatric disorders Treat any comorbid medical issues Address any psychosocial stressors Identify target behaviors Managing Behaviors • List target behaviors • Develop behavior intervention plan • Recruit support services to reinforce behavior plan Identify Target Behaviors • Target behaviors may differ depending on age range • List behaviors most least impactful • Type of intervention may depend on type and scope of behavior – Low acuity (oppositional, defiant, limit testing, noncompliant, mild aggression) – Moderate acuity (moderate aggression, bullying, destruction of property, truancy, running away) – High acuity (urgent/emergent behavior, i.e. threats of harm to self or others) Basic Principles • Pick and choose battles! – Some behaviors may require effective ignoring • Be consistent, persistent (as best as possible) • Behaviors may get worse before they get better • Identify any parent/caregiver behaviors that inadvertently reinforce negative behavior • Praise/positive reinforcement is more effective than consequence/punishment • Involve the child as much as possible Low Acuity Behaviors • Develop behavior intervention plan – Identify and teach rules – Determine consequences – Determine praise/rewards • Who is involved? – Parents – School – Therapist (behavior, play, individual, family) Moderate Acuity • Develop behavior intervention plan – – – – – – Prevention—teaching coping skills Safe de-escalation techniques Anti-bullying interventions in school Create non-aggressive environment External source of consequences (ie PINS program) MST (Multi-systemic therapy) • Who is involved? – – – – Parents School Therapist (in-home, behavioral, CBI worker, individual, family) DJS High Acuity Behaviors • Develop intervention plan – Maintain safety – Crisis evaluation – Safe transport to appropriate placement • Who is involved? – Crisis intervention services (911, ChAMPS: 202-481-1440) – Inpatient unit – DJS Resources for Parents • "The Kazdin Method for Parenting the Defiant Child."—Allen E. Kazdin, PhD • “Your Defiant Child”—Russell Barkley, PhD • “SOS Help for Parents”—Lynn Clark, PhD • “1-2-3, Magic”—Dr. Thomas Phelan • “The Whole Brain Child”—Daniel Segal • “No More Meltdowns”—Jed Baker Substance Abuse Screening & Brief Intervention Katherine Hobbs Knutson, MD, MPH 15 Substance abuse screening For adolescents, in addition to the SDQ screening (and suicide screening), DBH and the DC Collaborative recommend practices to additionally screen for substance abuse with the CRAFFT tool. CRAFFT screening tool, Children’s Hospital Boston, 2009. CRAFFT screening tool, Children’s Hospital Boston, 2009. Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Available at: http://www.integration.samhsa.gov/clinical-practice/sbirt/Guide_for_Youth_Screening_and_Brief_Intervention.pdf Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Negative CRAFFT screen Negative CRAFFT screen: provide positive reinforcement for abstinence, consider exploring the choice for abstinence with the patient. Positive CRAFFT screen Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf CRAFFT screening tool, Children’s Hospital Boston, 2009. Positive CRAFFT screen • “No” to all questions in part A + “Yes” to CAR question – Describe dangers of riding with a person who has been using alcohol/drugs – Consider “Contract for Life” Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf CRAFFT screening tool, Children’s Hospital Boston, 2009. Positive CRAFFT screen • “Yes” to one question in part A – Counsel patient on negative health effects of drug and alcohol use. – Try to identify a negative aspect of drug/alcohol use that the patient has recognized independently. – Agree to stop using drugs/alcohol. Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf Positive CRAFFT screen • “Yes” to >2 questions Positive CRAFFT screen • “Yes” to >2 questions – Assess type of drug(s) used, quantity and frequency Positive CRAFFT screen • “Yes” to >2 questions – Assess type of drug(s) used, quantity and frequency – Assess for substance use disorder diagnosis DSM 5 criteria for substance use disorder The new DSM describes a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance. 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 4. Craving, or a strong desire or urge to use the substance. 5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use. 7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance. 8. Recurrent use of the substance in situations in which it is physically hazardous. 9. Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. Tolerance, as defined by either of the following: -A need for markedly increased amounts of the substance to achieve intoxication or desired effect. -A markedly diminished effect with continued use of the same amount of the substance. 11. Withdrawal, as manifested by either of the following: -The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance). -The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. mild substance use disorder is suggested by the presence of 2-3 symptoms, moderate by 4-5 symptoms, and severe by 6 or more symptoms Positive CRAFFT screen • “Yes” to >2 questions – Assess type of drug(s) used, quantity and frequency – Assess for substance use disorder diagnosis – Assess patient’s willingness and perceived barriers to decreasing use Positive CRAFFT screen • Options for intervention: – Develop a plan to decrease use and follow up in 1 month within primary care to assess progress – For more serious substance abuse conditions, refer for specialty treatment – For safety concerns, refer to the ED Positive CRAFFT screen Motivational interviewing CRAFFT screen Part A, response Part B, response Risk level Intervention “No” to all questions “No” to all questions Low Praise good choices. “No” to all 3 questions “Yes” to CAR question Elevated Provide “Contract for Life.” “Yes” to 1 question “No” to all questions Elevated Recommend abstinence. “Yes” to >1 questions “Yes” to >1 questions High Assess for substance use disorder, motivational interviewing, refer for treatment. GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Behavioral Health Presentation Topic: Substance Use and Co-Occurring Treatment and Services Presentation Purpose: Provide Pediatric Primary Care Physicians information regarding programs and resources for youth with substance use issues in D.C. Youth Treatment Coordinator Nicole Martino, LICSW April 10th, 2015 DC Department of Behavioral Health Programs Four ASTEP (Adolescent Substance Treatment Expansion Program) Providers: Hillcrest Children and Family Center Latin American Youth Center Riverside Treatment Center Federal City Recovery DC Department of Behavioral Health Screening and Assessment Family of GAIN Instruments: An evidence based tool utilized to screen and assess for substance use and cooccurring mental health disorders GAIN SS- Screening GAIN I- Comprehensive Assessment GAIN M-90- Follow up (assesses changes) DC Department of Behavioral Health Treatment Adolescent Substance Use Treatment: All four ASTEP Providers are able to provide outpatient and intensive outpatient substance use treatment to include the following: Group Therapy Case Management Clinical Care Coordination Individual Therapy DC Department of Behavioral Health Treatment Continued… Co-Occurring Treatment: All ASTEP Providers are trained to assess for cooccurring disorders utilizing the GAIN Tools Three of the four ASTEP Providers are trained in the Evidence Based Treatment Model: ACRA (Adolescent Community Reinforcement Approach) Hillcrest Children and Family Center Latin American Youth Center Riverside Treatment Center DC Department of Behavioral Health Access to Services • Adolescents and their families can access services by contacting the Access Helpline for enrollment or by contacting any of the four ASTEP Providers directly to make an appointment. DC Department of Behavioral Health Contacts • Access Helpline: (888) 7WE-HELP/(888) 793-4357 • Four ASTEP Providers Hillcrest Children and Family Center: (202) 232-6100 Latin American Youth Center: (202) 319-2265 Riverside Treatment Center: (202) 889-3182 Federal City Recovery: (202) 548-8460 • Department of Behavioral Health- Assessment and Referral Center: (202) 727-8473 DC Department of Behavioral Health Questions? • Bhavin Dave, MD: [email protected] • Katherine Hobbs Knutson, MD MPH: [email protected] • Nicole Martino, LICSW: [email protected] 49