Managing common mental health problems in pediatric primary care

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Managing common mental health problems in
pediatric primary care

• Jane Foy, MD, and Larry Wissow, MD

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Goals

• Use interactive skills in the course of routine
  visits to improve clinical outcomes for children
  with emotional and behavioral problems
• Develop a personalized tool-kit of evidence based
  interventions for first-line responses to common
  emotional and behavioral problems

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Disclosure

• No conflicts to report
• Grateful to funders and collaborators
• Duke Endowment
• National Institute of Mental Health
• North Carolina chapter of the AAP

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Outline of workshop

• Lunch
• Getting acquainted
• Self-assessment
• About 2 hours to go over video clips of
  interactive skills
• About 1 hour to talk about a toolbox of
  broad-based treatment elements

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Background/philosophy

• Pediatric practices see same range of severity as
  child psychiatrists
• But distribution varies
• Many different ways to cope
• Good triage
• Develop your own skills
• Co-locate with mental health

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Core needs

• Efficiently rule out emergencies
• Provide immediate relief and advice
• Develop a mutually agreeable plan for next steps
• Stay in control of the visit and balance the
  needs of this patient with the needs of others

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To meet core needs

• Core capability for any solution might be called
  alliance with family
• Partnership, engagement
• Data from adult primary care studies of
  depression treatment
• Relationship with provider predicted engagement
  and outcome
• Van Os TW. J Affect Disord 20058443-51.
  Frémongt P. Encephale 200834205-10.

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Why start with a focus on alliance?

• Advice alone isnt enough
• lt 50 of psychosocial concerns disclosed
• lt 50 of mental health referrals kept
• lt 50 of children who start mental health
  treatment finish
• Evidence from psychotherapy
• Predicts outcome over and above any specific
  treatment (including medications)

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Elements of alliance in psychotherapy

• Agreement on nature of problem
• Agreement on what to do (and when to do it)
• Affective bond with provider
• Trust
• Optimism
• Relief

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The feeling

• How many feel they can tell when the relationship
  is working (or will work)?
• How do you know?
• How often are you right?

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Why alliance especially with mental health issues?

• Particularly stigmatizing
• Doubt and equivocation part of the illness
• Not sure that youre the one to tell
• Afraid to hear the answer

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What builds alliance?

• Evidence that process starts with initial
  interaction with office
• Image of relationship built from staff as a
  whole, not just those with most contact
• Patients value flexible, open staff who can
• pinch hit for each other
• help trouble shoot problems
• speed things up when needed
• realize when the patients context has changed
• Ware NC. Psychiatr Serv. 199950395-400.
  Pulido R. Arch Psych Nursing 200822277-87.

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Patient trust and practice climate

• Adult primary care patients trust in provider
  related to
• Physicians and staff reporting better
  collaboration with each other, more autonomy,
  ability to delegate to each other
• Trust then relates to
• Attribution of influence over healthy behaviors
  to provider recommendations
• Becker ER, Medical Care 200846795-805

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Alliance building 11

1. Feeling heard and understood (the bond)
2. Seeking agreement on a working formulation of the
   problem
3. Seeking permission to offer advice

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1. Feeling heard and understood

• Heard active listening
• Creating the illusion of taking time
• Verbal and non-verbal indicators of paying
  attention
• Interventions that co-construct the story
• Understood agreement on the nature of the
  concerns and the highest priorities

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2. Seeking agreement on a working formulation of
the problem

• Asking for permission to gather more information
• Opportunity to open up more sensitive areas, rule
  outs, emergencies
• Asking for permission to offer a preliminary idea
  of the problem
• Asking if youve got it
• Cycling back to more questions

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3. Seeking permission to offer advice

• Ready to act?
• If not, what would it take?
• What can we do now?
• What might we need to do next?
• Responding to no

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1. Feeling heard and understood
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Shaping concerns and managing time

• Open-ended questions
• Anything else
• Breaking into the long story
• Managing break-ins and rambling

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Skills for rambling (co-construction)

• I want to make sure we dont run out of time
• Summarize your understanding and ask for
  additional concerns
• Specifically ask for focus
• Which one of those is hardest?
• Pick one of those to start with.
• Ask for a specific example

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Pick one
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Two in the visit skills when turn-taking
interrupted

• Possible tactics
• Shift in body language
• Acknowledge and re-direct
• Reminder of rules
• Considerations
• Timing
• Status of person interrupting or interrupted

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Enforcing taking turns - child
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Skills when participants are angry at each other

• Rationale
• Want to manage negative affect in the visit (and
  help people move on to problem solving)
• Want to demonstrate that dialog is possible
• Several flavors of extreme statements
• Black or white statements leave no room for
  discussion
• Critical comments about family members
• Set-ups involving vague, value-laden goals

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Responding to black or white

• Characterized by always, never, or similar
  words
• Point out and ask for restatement
• Be prepared if you choose to challenge the
  generalization
• Alternative ask for something easier to hear

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Responding to black or white with say
something easier
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Common issues in agenda setting

• Parent and child/youth have different priorities
• Family priorities not same as yours
• Opportunities for additional visits are limited
• You really do want to accomplish more than you
  have time for!

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Skills for agenda setting

• Making sure this process is clear to
  patient/parent
• Playing back the list of concerns
• Asking for priorities
• Getting agreement from all parties
• Openly and collaboratively problem solve about
  limitations on follow-up visits

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2. Getting to agreement on a working formulation

• Why ask for permission to get more information?
• What is it that you want to know?
• Sensitive but important details
• Data related to possibly urgent treatment needs
  (including overall level of function)
• What they think might be the underlying cause

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Small group task

• Tables for issues that sound like they fall
  into broad categories of ADHD, depression,
  opposition, anxiety, substance use

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Small group task

• Brainstorm most efficient ways to ask about
• Overall function and possible indicators of need
  for urgent care
• Sensitive but possibly important information
  related to the child or family
• Somatic causes
• What child/family has already thought about as
  cause/underlying issue

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Reports from groups

• Focus on the first 2-3 minutes worth of questions
  that will help you decide where you are going
  with this problem

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Hint about severity/function

• Questions from SDQ
• Do the difficulties you mentioned distress you
  (teen) or your child (younger child)?
• How much?
• How much do they interfere with life?
• At home
• With friends
• In school
• In other activities

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3. Asking for permission to offer advice

• Summing up your thinking and checking for
  agreement
• May need to cycle back to get more information
• Do they still agree that this is something they
  want to do something about?
• If no, what should be monitored, what would it
  take?

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Giving advice

• Rationale
• Being directive can fail even when people want
  help
• Anxiety, ambivalence, shame, loss of control
• Medical provider is usually not the first person
  in the chain of consultation
• People come with prior ideas and opinions (about
  cause, condition, treatment) that need to be
  incorporated
• People will accept advice they cant follow
• Need to actively identify barriers

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Asking about readiness to act

• People may be aware of a problem but not yet
  ready to act on it
• The kind of advice needed depends on this stage
  of change
• Mis-matched advice likely to be rejected
• If ready get permission to give advice
• If not ready what would motivate action?

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What would be grounds to act?
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When you get to give advice

• Ask for permission
• Helps patients maintain sense of control
• Ask for their ideas
• Offer advice as set of choices
• Preferably include their ideas among choices
• Frame as short and long term plans
• What might help now
• What diagnostic steps to take

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Asking about barriers

• Easy to skip this step in a quick visit
• Evidence suggests even motivated patients
  appreciate help with logistics
• Asking allows people to think through and get
  more committed to plan
• Opportunity to build alliance and anticipate
  resistance

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Responding to resistance

• Overall, emphasize choice and time to discuss
• Apologize for getting ahead
• Agreeing with a twist
• What would it take?

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Getting information apologize for getting ahead
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Getting information what would be grounds to act?
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Agree with a twist and inform
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First-pass evidence-based intervention practice
elements

• Four clusters account for much of what is seen in
  primary care
• Low mood, anxiety, conduct, attention
• There are many evidence-based treatments for
  child mental health problems
• Though they vary in content and intensity,
  treatments for any one or related condition have
  many features in common
• Candidates for initial treatment
• (hawaii.gov/health/mental-health/camhd/library/pdf
  /ebs/ebs011.pdf)

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Practice elements for treating childhood anxiety
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Menu of common elements

• Anxiety
• Graded exposure, modeling
• ADHD and oppositional problems
• Tangible rewards, praise for child and parent,
  help with monitoring, time out, effective
  commands and limit setting, parent
  psychoeducation, response cost
• Low mood
• Child psychoeducation, cognitive/coping methods,
  problem-solving strategies, activity scheduling,
  behavioral rehearsal, social skills building

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A personalized, evidence-based, broadly
applicable toolkit
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When would you use these?

• Function good, watchful waiting, mild symptoms
• Holding pattern delay till mental health
  appointment
• Adjunct to medicationonly treatment

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Common elements for depression

• Psychoeducation
• Tactful and perhaps private exploration of family
  history (reduce stigma, increase empathy)

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Common elements for low mood

• Environment
• Reduce stresses and increase supports.
• Think about short term changes in demands and
  responsibilities for teen AND other family
  members
• Removing weapons, toxins, and alcohol regardless
  of concern for suicidality
• Talk about high prevalence and lack of
  relationship to character, strength, etc.
• Emphasize effectiveness (though slow pace) of
  treatment

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Common elements for depression

• Cognitive and coping skills (your favorites)
• Normalize common life setbacks and suggest
  mantras or self-talk
• Prescribe self-care (rest, good diet, exercise)
  as evidence-based approaches
• Prescribe relaxation and visualization (but may
  need someone else in the office to take the time
  to give instruction)
• Encourage a focus on strengths prescribe more
  activities that involve these things

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Problem-solving skills

• What small, achievable act would indicate
  progress?
• List difficulties/tasks
• Prioritize
• Give permission to concentrate first on one issue
  at a time

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Behavioral rehearsal and social skills

• Identify problem interactions that trigger low
  mood or conflict
• Can they be avoided?
• Are alternative responses possible?
• Mentally anticipate and practice responses.

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Medication for depression

• FDA labeled or good evidence for teens
• Fluoxetine (MDD)
• The black box warnings
• Increased thoughts not acts
• Paroxetine worst for agitation
• Benefit seems to outweigh risk
• For children 8 and older

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Medication effectiveness

• Number needed to treat about 10
• Response is slow need 12 weeks of increased
  doses at 4-week intervals to give a fair trial is
  see partial response
• For any treatment (med or not) continue 6-12
  months following recovery

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Common elements for anxiety

• Environment
• What real anxiety-provoking issues are present?
• Consider asking parent privately about
  undisclosed illnesses, losses, stresses.
• Are there catastrophic consequences for
  failure?
• Does the parent have an anxiety problem also?
• Help parents minimize their own displays of fear
  or worry.

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Graded exposure

• Ultimately goal is mastery rather than avoidance
• Underlying principle is de-sensitization
• Plan for gradually increasing exposure in
  supportive way
• Over time exposures get longer, more direct, less
  supported

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Graded exposure

• Imagining or talking about the feared
  object/situation
• Tolerating short exposures or looking at pictures
  with lots of support
• Tolerating progressively longer exposure in group
  or with coach
• Tolerating alone but with ability to get help

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Modeling

• Trusted adults engage in feared behavior or
  analogue
• Vocalize feelings, openly reveal their own
  anxieties and coping strategies
• Normalizing caution
• Model coping and safety strategies

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Medication for anxiety

• As with depression, modestly effective
• FDA approved and good evidence
• fluvoxamine (anxiety)
• fluoxetine (OCD)

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Summing up

• About organizational and educational needs?
• About building alliance?
• About core treatment elements?