Mental Illness in the Pediatric Population

1. Mental Illness in the Pediatric Population Webinar: March 15, 2013

2. What is Mental Illness? • According to NAMI (National Alliance of Mental Illness), 2013: • Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. • Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.

3. Common Diagnoses: • Adolescent Bi-polar disorder • Anxiety Disorders: • GAD • Panic Disorder • Phobias • OCD • PTSD • Anorexia nervosa • ADHD • Autism • Fragile X syndrome • (genetic condition involving changes in part of the X chromosome. It is the most common form of inherited intellectual disability in boys. Fragile X syndrome can be a cause of autism or related disorders, although not all children with fragile X syndrome have these conditions.) • Borderline Personality disorder • Depression • Impulse control disorder • Oppositional defiant disorder • Schizophrenia • Trichotillomania • Tourette’s syndrome • Fetal Alcohol Syndrome • Separation Anxiety

4. Diagnoses Authority: • Diagnostic and Statistical Manual of Mental Disorders, 4th Edition • A manual published by the American Psychiatric Association (APA) that includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of Diseases, commonly referred to as the ICD. • DSM-5is scheduled for release in May 2013.

5. Facts: • Falls along a continuum of severity • About 1 in 17 Americans, live with a serious mental illness • The U.S. Surgeon General -10% of children and adolescents in the United States suffer from serious emotional and mental disorders that cause significant functional impairment in their day-to-day lives at home, in school and with peers • Over 50% of students age 14 and older, with a mental disorder, drop out of high school—the highest dropout rate of any disability group • ½ of all lifetime cases begin by age 14, ¾ by age 24.6 yrs.

6. Facts (con’t): • World Health Organization (WHO) - four of the 10 leading causes of disability in the US are mental disorders. • By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children. • Usually strikes individuals in the prime of their lives, often during adolescence and young adulthood. • All ages are susceptible, but the young and the old are especially vulnerable. • Suicide is the 11th leading cause of death in the United States • 3rd leading cause of death for ages 10-24 years. • More than 90% of those who die by suicide have a diagnosable mental disorder • 70% of youth in juvenile justice systems have at least one mental disorder • at least 20% experiencing significant functional impairment

7. “This is a real issue for families and shouldn’t be ignored because it is uncomfortable. The earlier it is treated, the greater chance of recovery.” The Family Experience with Primary Care Dana Markey Program Manager, NAMI Child and Adolescent Action Center

8. Consequences to Individuals and Society when untreated: • unnecessary disability • unemployment • substance abuse • homelessness • inappropriate incarceration • suicide • violence toward others • wasted lives • face an increased risk of having chronic medical conditions. • Adults with serious mental illness die 25 years earlier than other Americans, largely due to treatable medical conditions. • *Untreated mental illness cost is more than 100 billion dollars each • year in the US.

9. Current state of treatment: • Fewer than ½ of children with a diagnosable mental disorder receive mental health services in a given year • Racial and ethnic minorities are less likely to have access to mental health services and often receive a poorer quality of care • Among the parents of children with serious difficulties: • 26% reported that their child received special education services for emotional or behavioral difficulties • 40% reported they had contacted a general doctor about their child’s emotional or behavioral difficulties • 45% reported they had contact with a mental health professional about their child’s difficulties.

10. Psychotropic Med txmt. per dx: • Teens with ADHD had the highest rates at 31% • 19.7% with a mood disorder like depression or bipolar disorder • Eating disorders, about 19% • 11.6 percent with anxiety disorders • Youth with severe bipolar disorder (1.7%) or a neurodevelopmental disorder such as autism (2.0%). • Reference • Merikangas K, He J, Rapoport J, Vitiello B, Olfson M. Medication use in US Youth with Mental Disorders. Archives of Pediatric and Adolescent Medicine. Online ahead of print Dec 3, 2012.

11. Treatment Stats: • Youth treated by a mental health professional were more likely to be receiving appropriate medication as opposed to those being treated within general medicine or other settings. • More research is needed on medication use among children younger than age 13. • Most adolescent youth taking psychotropic medications have serious behavioral, cognitive or emotional disturbances • Among those youth who met criteria for any mental disorder, 14.2% reported that they had been treated with a psychotropic medication

12. http://www.nimh.nih.gov/statistics/1NHANES.shtml

13. Populations at risk: • Concussion (hx) – for initial misdiagnosis • ACE (Adverse Childhood Experience) • Foster care (currently/past) • Hx. of abuse or molestation • Behavioral pxs at school • Any IP Psych • Family status change • Death in family (grief counseling) • New (existing) chronic disease dx • Low economic status (evidence based) • Autism • ADHD • Parental/Caregiver substance abuse (current/hx) • Domestic / Intimate Partner violence (current/hx) • Household member with Depression, Mental illness or Suicide {gesture}, cutting, self-mutilation (current/hx) • Household member in prison or litigation (current/hx) • *Majority of list compiled by CM’s at MSU Peds Subspecialty Clinic

14. *Note the behaviors that mirror changes associated with an Adverse Childhood Experience (ACE), Mental Illness (i.e., depression, anxiety) or Sleep disorders.

15. ACE: Adverse Childhood Experience • The ten ACEs are (in no specific order): • Emotional abuse • Emotional neglect • Physical abuse • Physical neglect • Sexual abuse • Drug addicted or alcoholic family member • Incarceration of a family member • Loss of a parent due to death, divorce, or abandonment • Mentally ill, depressed, or suicidal family member • Witnessing domestic violence • Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members.

16. ACEs and health in later life • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease (COPD) • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease (IHD) • Liver disease • Risk for intimate partner violence • Multiple sexual partners • Sexually transmitted infections • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of sexual activity • Early initiation of smoking • Adolescent pregnancy

19. Significant early adversity can lead to lifelong problems: As the number of adverse early childhood experiences mounts, so does the risk of developmental delays (top).

20. Adults with more adverse experiences in early childhood are also more likely to have health problems, including alcoholism, depression, heart disease, and diabetes.

21. ACE Questionnaire: http://www.acestudy.org/files/ACE_Score_Calculator.pdf

22. What’s Your ACE Score? • You get one point for each type of trauma. • The higher your ACE score, the higher your risk of disease, social, and emotional problems. • ACE score of 4 or more, things start getting serious: • The likelihood of chronic pulmonary lung disease increases390% • Hepatitis, 240% • Depression, 460% • Suicide, 1,220%

23. “Primary care physicians who can help identify potential mental illness can save a child and parent years of pain.” July 28th, 2011 AAP Future of Pediatrics Mental Health Preconference

24. American Medical Association (AMA): • Guidelines for Adolescent Preventive Services (GAPS) • program in your primary care clinical setting. • Algorithm • http://www.ama-assn.org/ama1/pub/upload/mm/39/gapsmono.pdf

25. American Medical Association: Guidelines to Adolescent Preventive Services: • From ages 11 to 21, all adolescents should have preventive services visits that address both the biomedical and psychosocial aspects of health. • For some adolescents, health risk behaviors may be interrelated. • Adolescents who are found to engage in one health risk behavior, consequently, should be asked about involvement • in others.

26. GAPS recommendations compared with Traditional approaches to adolescent health care

27. GAPS: Traditional:

28. 1ST Screen for Parents – begin conversation: http://www.aacap.org/cs/root/facts_for_families/facts_for_families_keyword_alphabetical • Contains a multitude of 1-2 page documents regarding many emotional, social, and psychological situations / diagnoses. • May print in PDF and place in waiting rooms.

30. Evidence-based Screening Tools: Separate document posted on mipctdemo website with forms and more detail: ADHD: Vanderbilt’s Autism: M-CHAT and CAST Depression: PHQ-9 Postnatal Depression: Edinburgh ODD: SDQ’s (forms for various ages) Adolescent Screening for risk behaviors / depression: HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuallity, and Suicide/depression) GAPS (Guidelines for Adolescent Preventive Services)tools Substance Abuse: CRAFFT Suicide: PHQ-9 or Adolescent Suicide Assessment Protocol (ASAP-20)

31. Referral Process: • Insurance driven • Go to insurance website – search for providers • Parents given names / numbers or list to call • Remind parents to sign waiver for consult info back to PCP • Call on their behalf • Makes a difference • Inquire as to comprehensiveness of services available to pt • Consider why the child is being referred: • Diagnostic screening for diagnosis • Medication management • Counseling • Send pertinent information • Temporary need vs. long-term diagnosis • Grief counseling

32. Primary Prevention: • Promote awareness • Encourage conversation with parents / teen • Ask appropriate questions: • (next slide) • Early screening • Early referral for counseling or grief support for known ACE’s: (Adverse childhood experiences) • Divorce • Sexual molestation or abuse • Bullying • Severe trauma • Hospitalization • Children of deployed parent • Foster children

33. Secondary Prevention: • Identify children at risk • Obtain referral and PA through insurance • Verify appt. has been obtained • Note: Some MH professionals will do the initial screening, but not offer the counseling or behavioral services interventional services. (based on financial reimbursements) • Create a Registry

34. Tertiary Prevention and Treatment: • Identify conditions of co-morbidity and treat • Provide ongoing support and open conversation for families • Open communication and ongoing evaluation • Provide resource information for parent-to-parent support groups (Mental Health America website) • Provide website links to evidence-based information (Resource • document) • Promote continued involvement in therapy and support groups • Coordinate care with schools

35. Impact of Treatment: • Between 70-90% of individuals have significant reduction of symptoms and improved quality of life • combination of pharmacological, psychosocial treatments and supports.

36. Emergency (Crisis) Intervention: • Call local CMH ES – first (if non-violent to self or others) • Individuals must be medically cleared first. • Takes place in the ED • App & Certs • Not required for less than 18 yrs of age, unless emancipated • Call insurance company for PA – usually done by ED CM or IP facility • Instruct parents to call the next day to ensure the insurance company has all necessary information and check on benefits, PA in place • Parents must take • Ambulance rides • Documentation needed

37. Michigan Laws - Right of a Minor: • Mental Health – Inpatient Care • Mental Health Code, MCL 330.1498d • • Parents may admit for inpatient care. • • Minor may consent to limited inpatient care if 14 years or older. • IS PARENTAL CONSENT REQUIRED? Required • • A minor of any age may be hospitalized for mental health reasons if a parent/legal • guardian or agency • requests and the minor is found to be suitable for hospitalization. • • A minor of 14 years or older may request, and if found suitable, be hospitalized. • • Suitability, in either case, shall not be based solely on one or more of the following: • epilepsy; developmental delay; brief periods of intoxication; juvenile offenses; or • sexual, religious or political activity. • IS PARENTAL ACCESS TO THE MINOR’S INFORMATION PERMITTED? Yes • http://www.michigan.gov/documents/mdch/Michigan_Minor_Consent_Laws_292779_7.pdf

38. Michigan Laws - Right of a Minor: • Mental Health – Outpatient Care • Mental Health Code, MCL 330.1707 • Minor may consent to limited outpatient care if 14 years or older. • IS PARENTAL CONSENT REQUIRED? Not required • A minor age 14 or older may request and receive up to 12 outpatient sessions or four months of outpatient counseling. • IS PARENTAL ACCESS TO THE MINOR’S INFORMATION PERMITTED? • Provider discretion applies • Information may be given to parent, guardian or person in loco parentis for a compelling reason based on a substantial probability of harm to the minor or to another individual; • mental health professional must notify minor of his/her intent to inform parent.

39. Munchausen by proxy • In MUNCHAUSEN BY PROXY (MBP), an individual falsifies or induces illness in another person to accrue emotional satisfaction—but this time vicariously.  This is a form of maltreatment (abuse and/or neglect) rather than a mental disorder. Children are the usual victims and the mother is the usual perpetrator. MBP is sometimes called "Fabricated or Induced Illness by Carer" (FII). • Question to myself & practice physicians • http://www.munchausen.com/

40. Pt. Care Transformation Model (example): • Currently hired by PO • Kim Roberts, MA, LLP (psychologist) • Master of Arts and Limited License Practitioner (no PhD.) • Embedded in a PCMH • 7-8000 clients in practice • Works 2 full days / week • Works mostly with ADHD • Performs Diagnostic tests / Assessments • Medication management • Follow HEDIS rules • Counseling: • Parenting • Cognitive • School • Play therapy for kids without ADHD • Paid hourly • Documents appropriately in EMR to substantiate billing • Recoup of cost through office via insurance reimbursement for services

41. Resource links: (Separate document posted on mipctdemo website with slides) NAMI (National Alliance on Mental Illness) NAMI Michigan Foster Care - Rights & Meds HIPAA for minors Resilience Trumps ACES Resilience / Stress Questionnaire American Academy of Child and Adolescent Society “Facts for Families” – download Mental Health America (resource for families and support group locator)