Child and Adolescent Mental Health in Primary Care

1
Child and Adolescent Mental Health in Primary Care

• Tony Guerrero, M.D.
• Pediatrician and
• Child and Adolescent Psychiatrist

2
Objectives

• 1. To introduce a primary care, family-centered
  approach to common mental health conditions
• Autism/PDD
• Mental retardation
• Oppositional behavior
• ADHD
• Learning disorders
• Adolescent mood disorders
• Psychological sequelae of abuse
• Psychosomatic symptoms
• Eating disorders
• Parental mental health concerns

3
Objectives (continued)

• 2. To review resources for the management of
  common mental health conditions presenting in
  primary care
• 0-3/early intervention services
• Parent line
• Parent management training resources
• Public education/public mental health services
• Suicide and crisis line
• Child protective services
• Interdisciplinary team for eating disorders

4
Objectives (continued)

• 3. To help me understand what issues you may be
  faced with out in the field, and how you feel
  primary care and mental health can optimally work
  together.

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Case vignette 1
Jimmy is a 2 ¼-year old male who recently
transferred to your care. He seems to have
delays in language, as he only is able to say a
few words clearly, while the rest of his speech
is unintelligible jabbering to himself.
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Case Vignette 1 (continued)
In addition, he is not yet pointing out objects
of interest to his parents. Although he has
moments of enjoying affection from his parents,
he is minimally interested in other children.
His parents do not recall any times he has
engaged in pretend play.
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Case vignette 1 (continued)
The parents report that Jimmy is receiving early
intervention services, which they are very happy
with. They say that he is delayed, but that
nobody really knows exactly whats wrong with
him.
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Stimulus questions

• What diagnoses need to be considered?
• How can the medical home access other services?
• Why are early detection and early family
  involvement important?

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Autism and the PDDs

• Autism 1/1000
• PDD in general 1/several hundred
• Phenylketonuria 1/12,000
• Congenital hypothyroidism 1/4000

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Conceptualization MR vs PDD

• Mental retardation static encephalopathy which
  affects the higher brain globally.
• Autism static encephalopathy which more
  selectively affects those parts of the brain
  affecting social connectedness (see handout).

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Mental Retardation vs.Autism Mental retardation

• Mental retardation
• General weakness in all areas
• Language ability matches overall development and
  used in social communication

• Autism/PDD
• Splinter skills
• Language, if present, not necessarily used in
  social communication

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Common myths about children with autism

• Most have high IQs
• Behaviors dont change/improve
• All lack eye contact
• All lack affection

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Condition affecting Brain functioning
Specific parts of the brain influencing social
connectedness
0-3 services Special ed.
All parts of the higher brain
Social disconnectedness
Relatively less natural motivation to
learn adaptive skills
Weaknesses in multiple areas of functioning
discrete trial training, etc.
Tendency to repetitive and sterotypic behaviors
Significant delays in language and communication
development
MENTAL RETARDATION
AUTISTIC DISORDER
Mental retardation and Autistic disorder Tony
Guerrero, 2000
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Autism-specific early intervention

• Break skills into small parts
• Build on skills already mastered
• Reward with intrinsic motivators (not necessarily
  the social connections that usually motivate
  children without autism)
• Consistency early intervention program, home

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Autism screening?

• CHAT (Baron-Cohen, Allen, and Gillberg, 1992)
  detection at 18 months of age.
• Questions on joint-attention behavior and
  pretend play.
• At 6-year follow-up (Baird et al, 2000)
  sensitivity of 38 and specificity of 98

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Possible medical workup

• Global developmental delays neuroimaging,
  karyotype/fragile X (Majnemer and Shevell, 1995)
• PDD incidence of Fragile X 0-16

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Accessing services Zero-to-Three
H-KISS (Hawaii Keiki Information Service System)
Calls Or faxes referral
Primary Care Physician
ELIGIBILITY Developmentally Delayed (incl.
social/emotional), Biologically at-risk for
developmental delay Environmentally at-risk for
developmental delay
Family contacted
CHILD AGE 0-3 AND FAMILY
Family interested in services
Central Point of Contact
0-3 psychological consultation
Care coordinator
Agencies providing care coordination Infant and
Toddler Development Programs Public Health
Nursing Healthy Tomorrows Healthy Start Etc.
HEITS (Hawaii Early Intervention Tracking System)
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communicate and arrange follow-up
get information from other providers,
caregivers, or programs
no
no
yes
have all info?
dev. delay or other risk?
see child and family
developmental/ behavioral screen
yes
insure involvement of H-KISS/ 0-3/ ITDP


Is the diagnosis and Tx
as clear to all as possible?
yes
no
specialty referral? (neuro, genetics, dev. peds)
no
major mental health issues?
yes
want state or private referral?
private
psych eval and treatment
Accessing the system Zero-to-three Tony
Guerrero, M.D., 2000
public
discuss with care coordinator and
insure communication
19
Case Vignette 2

• Johnny is a 3-year old child who has been your
  patient since birth. His mother is 19 years old
  and had behavioral difficulties as a teenager.
  She has done a reasonably good job with Johnny,
  but she reports that he becomes fussy and
  oppositional very easily, is very active, and
  throws mean tantrums.

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Case Vignette 2 (continued)

• Johnnys mother reports that she has tried to do
  time outs, but they dont work very well.
  However, he listens to his uncle (one of Johnnys
  four main caregivers), who tends to use corporal
  punishment.

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Troubleshooting time-outs

• Baseline positive relationship
• Immediacy
• Minimize negative attention
• Address environmental/parental barriers to
  consistency

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Which came first, behavioral difficulties in
child or dysfunctional parenting?
Parental emotional lability, limited support
network because of previous difficulties
a genetic factor which may predispose to
fussiness, ADHD
setup for negative interaction
temperamentally difficult infant or toddler
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Case Vignette 2 (continued)

• You commend Johnnys mother for her commitment to
  avoid corporal punishment. You spend the next
  few meetings collaborating with her on issues of
  behavioral management. You suggest appropriate
  resources, including the Parent Line and
  appropriate texts. You also recommend daily
  interactive play time with her son, and you give
  her a large binder to help organize the familys
  care of the many children in the household.

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Corporal punishment

• Straus, Sugarman, and Giles-Sims (1997)
  positive correlation between spanking and
  antisocial behavior 2 years later (other factors
  were controlled)
• They conclude replacing violent discipline with
  nonviolent discipline could reduce the level of
  violence in American society.

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Case Vignette2 (continued)

• Johnny is now 7 years old. At a well-child
  visit, Mother reports that Johnny is failing 2nd
  grade, possibly because of difficulty paying
  attention, possibly because of difficulty reading.

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Case vignette 2 (continued)

• After a careful evaluation and discussion with
  Johnnys teacher, you conclude that Johnny most
  likely has attention-deficit hyperactivity
  disorder and a possible reading disorder.
  Apparently, this is not really a surprise to
  Mother, who reports that (outside of your
  knowledge), Johnny had already seen a
  psychiatrist through the school. She was not
  willing to consider medications.

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Description of services Schoolage (3-20)
calls
Primary Care Physician
School Counselor
note this flowchart assumes that the need for
services is recognized as appropriate at each
step of the way.
or mails 042 form
Department of Education
CHILD
Contracted agency
psychoeducational testing
special education
mental health evaluation
eligibility determination
mental health services (e.g. psychotherapy, medica
tions)
Individualized Educational Plan (IEP) meeting
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communicate and arrange follow-up
get information from school, other providers, etc.
no
no
yes
have all info?
sig. behavioral problem?
see child and family
developmental/ behavioral screen
yes


Is the diagnosis and Tx
as clear to all as possible?
yes
no
suspected LD or MR?
yes
discuss with school counselor, initiate
042, insure communication
no
want state or private mental health
referral?
private
psych or dev peds eval/Tx
Accessing the system School-aged Tony Guerrero,
M.D., 2000
public
discuss with school counselor, initiate
042, insure communication
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Case Vignette 2 (continued)

• You continue to follow Johnny over the next month
  or two. You provide education on ADHD, and you
  try to address common misconceptions about
  medications. Mother continues to refuse
  medications, but she is very grateful for your
  caring, and she feels that things are going
  better especially after you reviewed earlier
  advice on behavior management.

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Facts about ADHD treatment

• Neurobiological specificity (Barkley, 1998)
• Decreased risk of substance abuse with treatment
  (Biederman et al, 1999)
• For core ADHD symptoms, medication management
  superior to behavioral treatment (MTA Cooperative
  Group, 1999)
• Percent of children with ADHD treated with
  stimulants 12.5 (Jensen et al, 1999)

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Case vignette 2 (continued)

• Johnny is now 13 years old. His mothers chief
  concerns are that he is very moody, that he
  becomes angry very quickly, that he has made
  suicide gestures when unable to have his way, and
  that he tends to have a bravado that gets him
  into trouble at school. He tends to not sleep
  very well.

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Case vignette 2 (continued)

• You notice that Johnny and his mother tend to
  banter raucously with each other in the middle of
  their arguments. There is no history of
  substance use or medical problems. There is a
  history of family members with law violations,
  drug use, and possible manic symptoms. They
  admit that things are a bit crazy at home.

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Mood disorder, chaotic family, or both?
parental emotional lability, limited support
network because of previous difficulties
a genetic factor which may predispose to a mood
disorder
setup for negative interaction and disordered
conduct
mood symptoms in adolescent
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Bipolar disorder?

• Up to 40 of children with conduct disorder have
  juvenile mania responsive to mood stabilizers
  (Biederman, 1999)
• Possibly predictive symptoms grandiosity,
  suicidal gesture, irritability, decreased
  attention span, and racing thoughts

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Reasons to exercise extreme caution with
antidepressants

• Studies other than Emslies (1997) fluoxetine
  study do not clearly point to antidepressant
  efficacy
• 20-30 of youth with major depression eventually
  have manic symptoms - risk of antidepressant-indu
  ced mania
• Possible kindling phenomenon with mood
  disorders (Papolos, 1999)

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Case vignette 2 (continued)

• You perform an appropriate medical evaluation and
  subsequently recommend that they see a child and
  adolescent psychiatrist. They appreciate the
  genuineness of your concern. Before they leave,
  you give them the phone number to the suicide and
  crisis hotline.

37
Case vignette 3 (continued)

• A 4-year old child has been reunited with her
  mother after having been in foster care because
  of sexual abuse. At an acute illness visit, you
  note concerns about frequent awakenings,
  nightmares, and nervousness.

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Case vignette 3 (continued)

• Question at this point, the priority
  intervention would be
• a) Initiation of individual play psychotherapy
• b) Prescription of a sleep-promoting medication
• c) Inquiry into the childs current
  circumstances and safety
• d) Prescription of an anti-depressant medication

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Cohen and Mannarino (1996)

• Structured family and individual therapy for
  sexually abused 3-6 year olds
• Goal improving parental ability to provide
  safety and support for child
• Goal appropriate discussion of trauma to
  correct misperceptions
• Superior to nondirective supportive therapy in a
  randomized study

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Case vignette 3 (continued)

• You are happy that you inquired into the current
  family circumstances. Mothers current boyfriend
  has been drinking heavily and, as a result, has
  been having erratic behavior around the mother
  and around the children. You collaborate with
  the mother and child protective services on a
  plan which eventually proves beneficial.

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Case Vignette 4

• Hauoli is a 10-year old female with recurrent
  episodes of vomiting which cause her to
  frequently miss school. Her physical examination
  is normal.

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Case Vignette 4 (continued)

• You note that the parents are divorced and that
  the child has an enmeshed relationship with the
  mother, who frequently gives in to her child,
  perceived as sickly. You consider the
  diagnosis of cyclic vomiting syndrome. With
  family counseling, the vomiting appears to cease,
  but the family seems a bit lukewarm in their
  investment in counseling.

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Case Vignette 4 (continued)

• Six weeks later, another episode of vomiting has
  started at school. You are unable to definitely
  identify new psychosocial stressors. You note in
  the medical history a previous report of
  headaches, occasional complaints of abdominal
  pain concurrent with the vomiting, and a family
  history of migraines.

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Common etiologies (Li, 1996)

• Cyclic vomiting
• Migraine 46
• Idiopathic 23
• GI (peptic, infectious) 12
• Sinusitis 12
• Metabolic 3
• Endocrine 3

• Chronic vomiting
• Peptic 40
• Infections 28
• Idiopathic 14
• Irritable bowel 10
• Sinusitis 10

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Why did I choose this case?

• Dysfunctional family dynamics sometimes result
  from a medical illness in a member
• Clearer etiologies for illnesses previously
  labeled as psychosomatic

46
Eating disorders

• Dysfunctional individual and family behavior may
  result from a starving brain/starving individual
• Initial priorities addressing medical concerns,
  medical re-feeding
• Team approach low threshold for referral

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Eating disorders (continued)

• Anorexia nervosa 10 mortality
• Bulimia nervosa sometimes confused with the much
  more dangerous anorexia nervosa, binging-purging
  type
• Carefully review DSM-4 criteria for anorexia
  nervosa weight less than 85 expected, intense
  fear of becoming fat, amenorrhea
• Indications for hospitalization

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Case Vignette 5

• Baby K is a 4-month old presenting for an upper
  respiratory infection. You notice that the mother
  is restless and suspicious and seems to have a
  labile mood (sometimes angry and abrupt, other
  times laughing and smiling). Baby has come
  regularly for well child visits and otherwise has
  a normal physical examination (other than a
  stuffy nose).

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Things to think about

• Any concerns about safety (baby, Mom, others) to
  mandate reporting?
• Any indications to refer for 0-3 services?
• Would the parent accept direct referrals?
• Can I see the child frequently in follow-up of
  medical conditions?

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Dos and donts

• Do ask questions to assess
• What parent is most concerned about (e.g., with
  URI)
• Why now (e.g., recent argument over childs
  health?)
• Do consider various explanations (e.g., long wait
  time, mood disorder, domestic violence, substance
  use, etc.)
• Dont expose yourself to medico-legal risk (e.g.,
  talking among staff, documenting, etc.)

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Parental mood conditions

• Post-partum mood conditions
• Importance of screening
• How to screen
• Possible symptoms and time-frame
• Possible impact on breastfeeding (Galler et al,
  1999), compliance with well-child care (McLennan
  and Kotelchuck , 2000), etc.

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Vital Statistics 2000

• What are the 2nd and 4th leading causes of death
  among all children and adolescents, 1-19 years
• Whats the 4th leading cause of death among 1-4
  year olds and 5-9 year olds?
• What are the 3rd and 4th leading causes of death
  in 10-14-year olds?
• What are the 2nd and 3rd leading causes of death
  in 15-24-year olds?
• (Hoyert et al, 2001)

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Take home points (hopefully)

• Early detection of autism/PDD and family
  involvement
• Access of 0-3 system
• Alternatives to corporal punishment
• Access of public services for children with needs
  for special education/mental health
• Accurate information about ADHD

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Take home points (continued)

• Identification of possible adolescent mood
  disorders relatively low threshold for
  referral/consultation
• Safety first in child with history of abuse
  work with family/environment
• Medical re-feeding for eating disorders low
  threshold for referral
• Attention to parental mental health

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Thank you for your attention!

• Tony Guerrero, M.D.
• 1712 Liliha St., Suite 305
• Honolulu, Hawaii 96817
• 537-1087 fax [phone]
• guerrera_at_gte.net