Managing common mental health problems in pediatric primary care

1. Managing common mental health problems in pediatric primary care Jane Foy, MD, and Larry Wissow, MD

2. 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

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

4. 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

5. 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

6. 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

7. 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.

8. 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)

9. 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

10. 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?

11. 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

12. 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.

13. 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

14. Alliance building 1:1 • Feeling heard and understood (the bond) • Seeking agreement on a working formulation of the problem • Seeking permission to offer advice

15. 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

16. 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

17. 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”

18. 1. Feeling heard and understood

19. Shaping concerns and managing time • Open-ended questions • Anything else • Breaking into the long story • Managing break-ins and rambling

20. Skills for rambling (co-construction) • “I want to make sure we don’t 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

21. “Pick one” Click box to start film clip 0021/Example7

22. 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

23. “Enforcing” taking turns - child

24. 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

25. 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”

26. Responding to “black or white” with “say something easier” Click box to start film clip mhvg0010/stronglang

27. 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!

28. 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

29. 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

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

31. 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

32. 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

33. 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

34. 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?

35. 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

36. 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?

37. What would be grounds to act? Click box to start film clip Gloss2/whatwouldittake2

38. 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

39. 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”

40. Responding to “resistance” • Overall, emphasize choice and time to discuss • Apologize for getting ahead • Agreeing with a twist • What would it take?

41. Getting information: apologize for “getting ahead” Click box to start film clip gloss10/example3_9cine

42. Getting information: what would be grounds to act? Click box to start film clip example3_10cine

43. Agree “with a twist” and inform Click box to start film clip example3_11cine

44. 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)

45. Practice elements for treating childhood anxiety

46. 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

47. A personalized, evidence-based, broadly applicable toolkit

48. When would you use these? Function good, watchful waiting, mild symptoms Holding pattern: delay till mental health appointment Adjunct to medication–only treatment

49. Common elements for depression Psychoeducation Tactful and perhaps private exploration of family history (reduce stigma, increase empathy)

50. 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