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Child and Adolescent Mental Health in Primary Care

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Title: 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.

5
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.
6
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.
7
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.
8
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?

9
Autism and the PDDs
  • Autism 1/1000
  • PDD in general 1/several hundred
  • Phenylketonuria 1/12,000
  • Congenital hypothyroidism 1/4000

10
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).

11
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

12
Common myths about children with autism
  • Most have high IQs
  • Behaviors dont change/improve
  • All lack eye contact
  • All lack affection

13
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
14
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

15
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

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

17
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)
18
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.

20
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.

21
Troubleshooting time-outs
  • Baseline positive relationship
  • Immediacy
  • Minimize negative attention
  • Address environmental/parental barriers to
    consistency

22
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
23
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.

24
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.

25
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.

26
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.

27
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
28
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
29
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.

30
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)

31
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.

32
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.

33
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
34
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

35
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)

36
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.

38
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

39
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

40
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.

41
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.

42
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.

43
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.

44
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

45
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

47
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

48
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).

49
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?

50
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.)

51
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.

52
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)

53
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

54
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

55
Thank you for your attention!
  • Tony Guerrero, M.D.
  • 1712 Liliha St., Suite 305
  • Honolulu, Hawaii 96817
  • 537-1087 fax 523-9029
  • guerrera_at_gte.net
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