Managing common mental health problems in pediatric primary

careJane Foy, MD, and Larry Wissow,

MD

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

Disclosure

• No conflicts to report

• Grateful to funders and collaborators– Duke Endowment– National Institute of Mental Health– North Carolina chapter of the AAP

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

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

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

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 2005;84:43-51. Frémongt P. Encephale 2008;34:205-10.

Why start with a focus on alliance?

• Advice alone isn’t enough– < 50% of psychosocial concerns disclosed– < 50% of mental health referrals kept– < 50% of children who start mental health

treatment finish

• Evidence from psychotherapy– Predicts outcome over and above any

specific treatment (including medications)

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

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?

Why alliance especially with mental health issues?

• Particularly stigmatizing

• Doubt and equivocation part of the “illness”

• Not sure that you’re the one to tell

• Afraid to hear the answer

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 patient’s context has changed

Ware NC. Psychiatr Serv. 1999;50:395-400. Pulido R. Arch Psych Nursing 2008;22:277-87.

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 2008;46:795-805

Alliance building 1:1

1. Feeling heard and understood (the bond)

2. Seeking agreement on a working formulation of the problem

3. Seeking permission to offer advice

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

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 you’ve got it– Cycling back to more questions

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”

1. Feeling heard and understood

Shaping concerns and managing time

• Open-ended questions

• Anything else

• Breaking into the long story

• Managing break-ins and rambling

Skills for rambling (co-construction)

1. “I want to make sure we don’t run out of time…”

2. Summarize your understanding and ask for additional concerns

3. Specifically ask for focus • “Which one of those is hardest?”• “Pick one of those to start with.”• Ask for a specific example

“Pick one”

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0021/Example7

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

“Enforcing” taking turns - child

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

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”

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!

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

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

Small group task

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

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

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

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

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?

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 can’t follow• Need to actively identify barriers

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?

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

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”

Responding to “resistance”

• Overall, emphasize choice and time to discuss

• Apologize for getting ahead

• Agreeing with a twist

• What would it take?

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)

Practice elements for treating childhood anxiety

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

A personalized, evidence-based, broadly applicable toolkit

When would you use these?

• Function good, watchful waiting, mild symptoms

• Holding pattern: delay till mental health appointment

• Adjunct to medication–only treatment

Common elements for depression

• Psychoeducation– Tactful and perhaps private exploration of family

history (reduce stigma, increase empathy)

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

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

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

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.

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

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

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.

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

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

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

Medication for anxiety

• As with depression, modestly effective

• FDA approved* and good evidence– fluvoxamine* (anxiety) – fluoxetine* (OCD)

Summing up

• About organizational and educational needs?

• About building alliance?

• About core treatment elements?