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Depression and Anxiety Disorders of Children and Adolescents. Internalizing Disorders Sheree Shafer, MSN, CRNP, FNP-BC, PMHCNS- BC Doctor of Nursing Practice Program Robert Morris University Department of Nursing and Health Sciences. Objectives. - PowerPoint PPT Presentation
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Depression and Anxiety Disorders Depression and Anxiety Disorders of Children and Adolescentsof Children and Adolescents
1. Provide systematic identification of children and adolescents at risk for depressive and anxiety disorders
2. Provide a comprehensive assessment and evaluation of children and adolescents with ADHD
3. Integrate knowledge of the use of
screening tools as part of the evaluation of ADHD in children and adolescents into practice
4. Provide systematic follow-up and management to children and adolescents with depressive and anxiety disorders
Psych0therapy: treatment in which a therapist and patient(s) work together to ameliorate functional impairment through focus on the therapeutic relationship
Therapist: one who treats illness or disability
Behavioral Health Evaluation: process for screening, diagnostic, and treatment planning
Triage: a process of sorting individuals based on their need and likely benefit from immediate treatment
Follow-up visit: scheduled medical visit to evaluate ongoing status or treatment response
Active Monitoring: treatment plan that includes regular visits, supportive care, and treatment goals while awaiting specialty care
DepressionDepression: A change in mood characterized by sadness, irritability, negativity for at least two weeks
1. Sad, down, negative mood, empty feeling
2. Anhedonia
3 & 4. Changes in sleep and appetite (scored as separate symptoms)
Irritable, easily frustrated, argumentative. Focused on negative events, interprets events as negative, discounts positives. “I don’t care” attitude
Not enjoying or quitting activities (self or account by others)
May sleep, eat more or less.
5. Decreased concentration, decisiveness
6. Psychomotor agitation or retardation, observable by others
Easily swayed by others, changes mind, may question if developed ADHD, amotivation
Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation
7. Complaints of fatigue
8. Feelings of worthlessness or excessive guilt
9. Death wish, Suicidal ideation, not a fear of death
Regardless of increased or decreased sleep
Negative about self, low self esteem, may feel responsible for events out of their control, discount positives and focus on negatives
May think family would be better off without them for fleeting moments or chronically, think life isn’t worth it, want to hurt self but no plan, or have a plan, and/or intent
At least 5/9 symptoms and noted dysfunction
5-6 symptoms= “mild” depression 6-7 symptoms=“moderate” depression 8-9 symptoms &/or suicidal
thoughts=“severe” Believe there is a depression but
inadequate amount of symptoms for diagnosis endorsed=“Depressive D/O NOS (not otherwise specified”
Specify single episode, recurrent, with psychotic features
Treatment Response: Period of significant decrease in symptoms or no symptoms for at least 2 weeks
Remission: Period extended 2 weeks-2 months
Recovery: Period greater than 2 months
Relapse: DSM depression reoccurs during remission
Recurrence: DSM depression occurs during recovery (new episode)
Major Depressive Disorder, recurrent, severe, with psychotic features (describes individual with 8 symptoms, second episode, and believes others are able to read their thoughts)
DysthymiaDysthymia: Sad down mood that does not fully meet criteria for depression, symptoms present for at least one year (Down mood and two other symptoms)
Irritable Appetite Change Low energy Low self esteem Difficulty making
decisions/ poor concentration
Feelings of hopelessness
Little motivation
“Reactive depression”
Overreaction to a situation as noted in mood and emotions but not fully meeting criteria for depression
If criteria is met for depression: diagnose depression
296.20 Major Depressive Disorder (MDD), unspecified (NOS)
296.21 MDD, mild 296.22 MDD, moderate 296.23 MDD, severe, without psychotic
features 296.24 MDD, severe, with psychotic
features 296.25 MDD, partial remission 296.26 MDD, in full remission Recurrent MDD, change “.2” to a “.3” for
bolded diagnosis Dysthymic D/O, 300.40 Adjustment D/O, 309.28
20% of teens will experience a clinical depression before adulthood
8% of teens suffer from depression at any one time (AACAP, 2007); adults one year point prevalence is 5.3% (Surgeon General Report, 2008)
Research: Point prevalence for adolescents with depression being seen in primary care:
GLAD-PC:II, 2007
2828%
A teen depressive episode usually lasts 8 months, or longer (8.3% will experience depression for at least one year)
40% will experience a reoccurrence of a depressive episode within 2 years, 70% before adulthood
Teens with depression have a higher incidence of STD’s, pregnancy, substance abuse, physical illness and complaints; lower rate of seeking higher education, satisfaction in relationships
30% will develop a substance abuse problem
Untreated depression is the number one cause of suicide
A depressed teen is 12 times more likely to attempt suicide
Less than 33% of teens with depression get help, but 80% could be helped with treatment
2/3 have a co-morbid condition (anxiety, dysthymia, substance abuse problem, ADHD, ODD, conduct disorder)
20% of those with a depression as a child or adolescent will eventually develop bipolar disorder. (Bipolar disorder=manic episode)
American Academy of Child and Adolescent Psychiatrists: “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders” (2007)
American Pediatric Association: Guidelines for Adolescent Depression in Primary Care, “GLAD-PC Tool Kit” (2007)
Family history of mood disorders, depression
Past history of depression Other psychiatric disorders (anxiety,
externalizing disorders) Substance abuse Trauma Psychosocial adversity Chief complaint of emotional problem Chronic Illness
PRE-PUBERTAL CHILDREN
Increased somatic complaints
Psychomotor agitation Mood congruent
Hallucinations School refusal Phobias, separation
anxiety, increased worry
ADOLESCENTS
Irritability Apathy: “I don’t care”
attitude Low self esteem Aggression / antisocial
behavior Substance abuse Can give a reliable
and detailed history
PRE-PUBERTAL CHILDREN
1-year prevalence 0.4-2.5%
Female/ Male Ratio: 1/1
Increased risk for bipolar
ADOLESCENTS
1-year prevalence 8-9%
Female/ Male Ratio: 2/1
Screening tools, not diagnostic GLAD-PC refers to scales as “diagnostic
aids” Help to objectify significance of
symptoms Provide talking points Important to know ages and settings in
which the tools were tested Be a part of behavioral evaluations and
ongoing management
User friendly, free, takes 5-10 minutes to complete, seconds to score
Both a child and parent form A score of 20 or more is considered to
be significant for depressive symptoms, 29 or greater highly sensitive and specific for depressive disorder
Specific for depression Tested in 7-19 years including non MH
clinic patients
Tested in primary care, and extensively Child, parent, teacher forms Exclusive for depression 5-10 minutes to complete, seconds to
score Not public ($.20 per scale) Appropriate for 7-17 years Significant sore 13 or greater Has subscales to measure mood, self
esteem, ineffectiveness, anhedonia, interpersonal problems, and inconsistency index
Establish basic rules: confidentiality, when confidentiality must be broken
Interview t0gether and alone, parent before child
There are no wrong answers Not a time for discussion of treatment When do you remember being happy How long have you felt this way Beware of assumptions
OnsetLocationDuration
Characteristics (mood, thoughts, behavior)
Associated symptomsRelieving FactorsTiming
Pregnancy, birth, delivery Infancy Toddler years Preschool K-third grade 4-6 grade Junior high Senior high Include development, social, medical,
and family history, ADL’s
Determine symptom severity & progression
Frequency
Intensity
Duration
Impairment?
Completed Act: Male/Female Ratio 4:1 Attempts: Female/Male Ratio 2:1 Diagnosis of Depression (Most significant
risk factor in females) Previous suicide attempt (Most
significant risk for males) Substance Abuse Problem/ Disruptive
Behavior (two fold increase in males) Stressful life event (individual
perception) Low levels of parent-child communication
Real or media accounts of suicide (locally, intensive media coverage, fictional character): increases risk in vulnerable teens, especially young teens
Availability of lethal agents History of trauma Family history of suicidal behavior 60% of those with depression have
thought about suicide, 30% attempt (AACAP, 2001)
Death wish, suicidal thoughts, acts Any plan, organization of the plan Preoccupation with morbid or death
related music, games, art work, books, TV shows
Availability of firearms, ropes, poisons, alcohol/drugs, sharp knives
Giving away possessions Loss of rationale thought Protective factors
Appearance, behavior, attitude
Characteristics of talk
Emotional state, affective reactions
Awareness, insight, reasoning and judgement
Expansive mood, tantrums that we could not replicate in terms of energy and duration, has times with decreased need for sleep. Behaviors not specific to home.
Appear and feel energetic and overly confident, feel special, risk taker
Talk rapidly, loudly, c/o racing thoughts Work / activities completed creatively, but
disorganized Sexually preoccupied, uninhibited Decreased need for sleep (hallmark
symptom) A Change!!!!
DSM criteria: Elevated mood + 3 Irritable mood + 4
Distractibility Insomnia Grandiosity (increased pleasurable
activities)
Flight of ideas Agitation, or increased goal directed
activity Self esteem inflated Talkative (increased)
Drug and Alcohol Abuse: Depressive symptoms occur in context of use
ADHD: May occur co-morbidly with depression. Note specifics of low self esteem, concentration, amotivation
Adjustment Disorder: Question of many social pressures: if meets criteria for depression, diagnose it
Dysthymia: May occur co-morbidly with depression (rare diagnosis)
Thyroid: check growth and development family history, low thresholdAnemia (complaints of fatigue,
irritability, diet concerns): check CBCCMP: general work-up Obstructive Sleep Apnea: Noted
abnormal snoringAdverse medication reaction
(prescribed and nonprescribed)
DSM DIAGNOSIS
Relational Problem
Anxiety D/O
DEFINITION
Significant family, peer relationship issues out of context with depressive symptoms, and a need to address in treatment (Divorce, adolescent relationships)
Often co-occur, (fear that is stuck)
Identify and screen those at risk Evaluation for depression, basic
differential diagnosis, co-morbid disorders Use behavioral screens Perform risk assessment, complete a
safety plan (contract) Perform psycho-educational ,
supportive counseling Refer as needed Establish responsibilities/roles of the
provider, patient, family Schedule follow-up appointment,
goals
Identify adult(s) who are available and whom the adolescent will contact
Establish reasons to contact those adultsGive emergency numbersDetermine the adults will use the
emergency numbersEstablish a regular check in time with
the adults and health professional
Mental Illness Clear and present danger to self or
others Behavior, due to a mental illness, likely
to result in death in the near future Unwilling to sign voluntary admission Appropriate to use 911 as needed Hospital provides safety,24 hour
management
Patient: Open mind toward treatment, adhere to safety contract, honesty, healthy lifestyle changes
Family: Remain healthy, provide encouragement, follow safety contract (Consider own support)
Clinician: Follow-up every one-two weeks
Refer or treat
De-stigmatize depression Provide general facts on depression Counsel on evidence based treatment
options, need for compliance with appointments
Restore hope, past effective copers Assist with problem solving barriers to treatment Provide active listening and reflection Provide written information Case management: Contact with schools, other
health providers Recommend healthy life style Safety Contracts
Cognitive Behavioral Therapy (CBT)
Medication Only (SSRI’s)
Combination Therapy: SSRI’s and CBT
Prudent Mental Health Services in
Primary Care
Enhanced Mental Health Services In Primary Care
Treatment AsUsual: not acceptable
Level of Comfort Caution with severe depression, co-
existing conditions (previous differential diagnosis), maladaptive behaviors
Caution if roles & responsibilities (including confidentiality) of provider, family, patient can not be agreed upon
Patient &/or family desire alternative treatment that is not evidenced based practice
There is no incorrect answer, honesty is all that is needed
Parents become coaches Compliance with appointmentsParticipate /develop realistic
treatment goals
Safety Contracts
Medication management plus / minus counseling from another source
Medication management and brief psycho-therapeutic intervention
Establish goals, interventions with patient, family input (medical home model)
Reevaluate every 6-8 weeks for progress toward goals (Choose dates): scales, parent and self report
Repeat scales no more than every two weeks
Reconsider treatment plan / diagnosis if not making progress
General commitment to treatment : At least one year
Receive diagnosis and rationale, treatment options and rationale, treatment plan, treatment goals, progress toward goals
Participate in the treatment planning, goal setting
Communicate, ask about suicidal thoughts, plan, action (all members)
Activate emergency plan as needed Assist/support with any daily activities
agreed upon
Diagnosis, rationale, neurochemical theory, evidence based treatment options and rationale, pro’s and con’s of the treatment options
Participate in developing treatment goals
Open mind toward techniques / medications recommended
Practice techniques Participate in development / adhere to
safety contract
Neurological system of the body was the first “wireless” system
Thoughts activate nerve pathways, chemicals are released in response to activation
Chemicals called neurotransmitters Neurotransmitters: Serotonin &
Norepinephrine modulate mood and anxiety
Decreased supply of these chemicals=depression/anxiety
Neurochemical supply is manufactured in nerve cells and broken down by nerve cells so a fresh supply is always available
Decreased supply related to genetic factors, stress, unknown factors
Medications and specific forms of psychotherapy enhance levels of these chemicals
Medications of choice decrease the breakdown of serotonin so more of your natural chemical is available
Effectiveness has been researched extensively, and in primary care
Most effective for those who are motivated, have some insight into their mood and stressors
Require daily work (average 15 minutes)
Premise: Thoughts and behavior affect feelings, automatic thoughts
Self awareness through daily journaling: stressors, “spiral” thinking
Stressful situations that can not be changed: relax mind , body, world
Stressful situations that can be changed: problem solving
Skills have to be learned, practiced
Concept developed by Albert EllisRealized he taught the same
concepts to depressed patientsStudied and described the thought
patterns of depressed individuals
Adapted for childrenWell tested in research
Mind Reading
Forecasting
Discounting
Critical of self and others
Feelings are facts
Self blame
Interpret others actions
Decide a future event will turn out negatively
Dismiss positives, focus on negatives
Exaggerated responses
If I feel this way, then this is the way it is
Hold self responsible for events not within one’s control
Spiral Thinking Friend did not say hi to me(Internalizes, Assumes friend is mad, doesn’t ask questions, “mind reading”)
Looks sad, decreased eye contact, others avoid. Generalizes, “I have no friends” (All or nothing, critical )
I am worthless (Feelings are facts) Feels hopeless, happless, helpless to change situation
MOOD
Rate mood on scale of 1-10 Think of your worst memory=1 Think of your best memory=10 Rate mood for AM, PM, evening, overall
mood for day. Few phrases about events that effected
mood Bring to visit; if forgets, do a 24 hour recall,
ask about events for the week. If gives a couple of negative accounts, as about other days
Gives a brief overviews of the time between visits
Decreases ability to discount positives
Discovery of themes (stressors, negative thought processes)
Allow for development of intervention
Body (Diaphragmatic Breathing)
Activate the vagus nerve
Breath in, hold, out: each to the count of 4 or 5 seconds
Concentrate on the breathing
Perform 4-5 times Can be used in
combination with other techniques
Progressive Muscle Relaxation
Yoga, general exercise
Tighten Specific Muscle Groups, relax. Usually performed with the assist of a coach (CD, etc)
Imagery Visualize a safe and content memory through all the senses, picture self there. Encourage to play their own DVD in their brain
Activities that are safe, relaxing and adaptive
Question what relaxes one now, build on those skills
Examples: reading, movies, talking to friends, music, sports
Avoid video games
What is the problem (“I” terms, be specific: not acceptable to state I feel bad at school”)
Possible Solutions: Brainstorm
Pro’s and Con’s each solution, chose the one with the most positives, least negatives
Implement and Evaluate
Possible Solutions Pro’s Con’s
Result:
Dealing with guilt: Learning from mistakes= positive experience
Assertiveness training is imp0rtant part of possible solutions for problem solving
Parent Role: co-therapist if invited by child, can provide incentives for practicing skills, can practice with child, assist with journal
Aggressive
Passive or Passive-Aggressive
Assertive
“You” statements, attack others
Do or say nothing; or make up an excuse, use diversion
“I” Statements: I feel (name feeling) because (reflect observation)
Knowledge of appropriate therapy Fits well with nursing philosophy Can be performed within a 25 minute
office visit Teaching a part of CBT is helpful Does no Harm TADS, NIMH study, (2004)
demonstrated that medication plus CBT decreased suicidality, best outcome
Treatment team may choose medication as initial intervention, or if psychotherapy fails
May be only provider, or as a collaborative team member with a therapist
Accompanied at least by psycho education
Selective Serotonin Reuptake Inhibitors (SSRI’s) are first line
Fluoxetine has FDA approval for depression and OCD in children 7 years and older, positive studies for citralapram (Celexa) & Sertraline (Zoloft) published
Act over time Daily compliance is important Parents manage medication supply
SSRI Starting Dose
Increments: Every 2-4 weeks
MaximumDaily Dose: once daily
Available Doses
Fluoxetine(Prozac)FDA approval to 7 years for depression
10 mg qd 10-20 mg 60 mg in AM 10 mg tablets10, 20, 40 mg pulvules20 mg/5 cc
Sertraline(Zoloft)FDA approval to 6 years for OCD
12.5-25 mg qd 12.5-25 mg 200 mg 25, 50, 100 mg tablets
Citalopram(Celexa)
10 mg qd 10 mg 60 mg 10, 20, 40 mg tablets
Escitalopram(Lexapro)
5 mg qd 5 mg 20 mg 5, 10, 20 mg tablets
Hypomania / mania
Akathisia (physical restlessness)
Serotonin syndrome (fever, hyperthermia, restlessness, confusion)
Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)
Dry Mouth Constipation/
Diarrhea Sweating Sleep Disturbance Headache Agitation or
jitteriness Appetite changes Rashes Sexual dysfunction
Disinhibition: (risk taking, impulsivity that is out of character)
Discontinuation Syndrome may be noted daily in some youth, split dose
(not a problem for Fluoxetine)
Not a cause of significant weight
Not addictive
Does not change one’s personality
Not a crutch
Start Low, Go Slow Side effects usually occur right away
with initiation or increased dose, can go away
Discontinue and see for hypo-manic symptoms
Follow guidelines by AAP for follow-up Knowledge of FDA Black Box Warning Titrate off medication slowly
Category “C” but Paroxetine (Paxil) to be moved to category “D”
Risk vs. Benefit
Emerging data noting jitteriness, mild respiratory illness, weak cry, poor muscle tone, excessive rapid respirations in infants who were exposed to SSRI use in third trimester
Based on a 2004 FDA review of reported adverse events in 23 clinical trials which involved 4,300 children & adolescents, 9 different medications
Studies used two different measures for suicidal thoughts & behavior
FDA clumped both thoughts & behavior as “suicidality”
First measure: “Event Report” Must be asked
Second measure: (17/23 studies) “Standardized Forms” questioned suicidality at each visit.
Second Measure technique considered more accepted
Studies that used event reporting noted that 2% receiving placebo expressed increased suicidality compared to 4% on medication
Studies that used standardized forms that questioned suicidality at each visit demonstrated a slight reduction in suicidality for the medication group
Significant Finding: No one in the Clinical Trials Committed Suicide!!!!!!!
FDA initially recommended weekly x 4, every two weeks x4, then in 4 weeks
AAP (GLAD-PC:II, 2007) and AACAP Practice Parameters, 2007, recommend following FDA guidelines
AACAP recommends ongoing monthly monitoring for 6 months after full remission
Follow-up can be a combination of face-to-face visits and phone contact
Increased severity of symptoms, risk factors, & suicidality increase the need for contact
Evaluation, Counsel diagnostic impression, treatment options (EBT), establish goals
Risk Assessment!!!!Safety plan. May begin treatment with
medication. Introduce journal keeping Plan next visit
Review major symptoms, treatment options, plan, current status, compliance.
Risk Assessment
Review safety plan
Review journal for mood, events, discovery of themes
Teach relaxation
Review major symptoms, plan, current status, compliance, safety plan
Repeat scales and review Review journal for mood, events,
discovery of themes Review use of relaxation, use,
effectiveness. May teach other relaxation.
Continue journal and add what makes things better
Review major symptoms, plan, current status, compliance, safety plan
Review journal for mood, events, discovery of themes
Review use of relaxation, use, effectiveness.
Teach problem solving Continue journal, add in use of
problem solving
Review major symptoms, plan, current status, compliance, safety plan
Review journal for mood, events, discovery of themes , use and effectiveness of skills
Repeat scales
Review treatment goals, plan
Maximize medication unless side effects noted
Active monitoring: increase intensity of care
Psychotherapy 6-8 weeks: Consider adding Medication
Maximized Medication Dose: Consider another medication, or adding CBT
Psychiatric Consultation if fails 1 or 2 medication trials
Always be reconsidering diagnosis
Identify youth with risk factors &/or cc of emotional problems
Establish screening processEstablish plan for systematically
screening high risk youth Establish assessment process based
on DSM IV which includes patient and family interviews
Safety evaluation (symptoms, availability of lethal items)
Provide Supportive CounselingEstablish Treatment PlanEstablish links / collaboration with
mental health resources in the community
Facilitate referralsActive monitoring: continue contact
every 1-2 weeks
Generalized Anxiety Disorder (everything)
Social Phobia (scrutiny)
Separation Anxiety Disorder
Panic disorder, with or without agoraphobia
Anxiety Disorder NOS
Psychological Factors Affecting Medical Condition (abdominal pain, headaches)
Somatoform Disorder NOS
Essential feature is excessive worry (apprehensive expectation, fear of the future) more days than not for at least 6 months
Difficult to control
In children, one of the following: c/o restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
Essential feature is anxiety caused by exposure to a feared social situation, duration of at least 6 months
Attempt to avoid social situations, or endure at great distress
Occur in peer settings, not just with adults
Children may cry, tantrum, freeze, or shrink from the exposure
Must have the capacity for age appropriate social interaction with familiar people
Onset from preschool until 18 years of age
Duration at least 4 weeks
Developmentally inappropriate worry r/t separation from home or to whom one is attached
Three of the foll0wing are present: Distress with separation or anticipated separation, worry of harm to caretakers, worry of untoward event causing separation, physical complaints with separation or anticipated separation, repeated nightmares of separation
Disorder of prominent anxiety or phobic avoidance but does not meet criteria for specific anxiety disorder
A general medical condition is present
Stress precipitates or exacerbates the general medical condition
Stress may interfere with treatment of the medical condition
There is a close relationship between stress and increased symptoms of the medical condition
Pain in one or more anatomical sites of the body without physiological cause or general medical condition
Not intentional as in malingering or factitious disorders
Symptoms not better accounted for by a depressive or anxiety disorder
Effects 10-20% of population
Most common behavioral disorder
Often precedes depression, or occurs co-morbidly
Associated with higher levels of somatic symptoms in children and adolescents
Genetics
Environment
Trauma
Chronic Illness
Cardiac PalpitationsHyperthyroidismSeizure DisorderHypoglycemic EpisodesCaffeine AbuseMedication effect (OTC or
prescribed)Substance Abuse
Tested in 7-17 yearsResearched and found to be
effective in primary care
Child and parent form
Few minutes to scoreMeasures general, separation, social
phobia, school phobia
Preschool=predominantly separation
School age= worries decrease for separation and focus on performance
Adolescents= worries of peer acceptance
Follows Erikson’s developmental theory
Modulated by Serotonin
Effects on other neurotransmitters
Effects of long term anxiety
Everyone has fearWhat are your fearsSome your age fear….Do you have those fears everydayHow do you stop themWho do you talk to about your fears
Use OLDCART, timeline as with depression
Less research, especially in primary care Research has demonstrated effectiveness
of CBT and SSRI’s Pilot study, quasi experimental design,
demonstrated utility of 8 sessions of CBT delivered in primary care vs. treatment as usual
Study of 448 children 7-17 years demonstrated significant improvement with Sertraline and CBT over each separately, over placebo
Educate on fearFear is a healthy , keeps us safeSometimes fear gets “stuck,” that is
anxietyWE can learn to use our mind, body,
world to overcome our fearsWe then use our ”tools” to
systematically face our fears
Fear causes our body to get ready for “fight or flight”
Flight = avoidanceFight = tantrumFear effects many parts of our body
(eyes, lungs, heart, stomachAvoidance helps the moment,
strengthens the fear
THERE IS A WAY OUT!
Similar to depression (relaxation, problem solving), but include planned exposures once coping skills acquired
Patient must assist with plan development
Parents may serve a co-therapists, incentives for work on anxiety management
Is at risk for depression
Keep self and family unit healthyBe a positive role modelAssist with use of tools and
exposures as plannedProblem solve current problems,
futuristic problems = anxietyBe efficient with time before
exposure
“Flood” with exposure
Intervention for acute onset anxiety without co-morbidity (separation anxiety, school phobia)
Evaluate effectiveness in 2-3 weeks
Best practice for identification, accurate diagnosis, and treatment
Patient outcomes
Appropriate setting
Neuro-chemical etiologies, effects of treatment vs. nontreatment
Axis I (Diagnosis, focus of treatment)
Axis II (MR and personality disorders)
Axis III (Physical illnesses)
Axis IV (Psychosocial stressors)
Axis V (Global Assessment of Functioning)
Description Code Total Visit Time
Counseling Time
New patient, level 3
99203 30 minute 15.5 minutes
New patient ,level 4
99204 45 minutes 23 minutes
New patient, level 5
99205 60 minutes 30.5 minutes
Established patient,Level 3
99213 15 minutes 8 minutes
Established patient, Level 4
99214 25 minutes 13 minutes
Established patient,Level 5
99215 40 minutes 20.5 minutes
Be specific
Example: 25 minute visit with 20 minute counsel on behavioral modification, specific plan developed. Parents agree to______
Example for maintenance care: 25 minute visit with 20 minute counsel on s/s, role of medication, importance of compliance, possible s/e, treatment options and goals, usual f/u treatment rec’s. Parent and child pleased with current level due to ability to (functioning level), desire no changes. Contracts for safety, will tell Mother of any changes, dangerousness. Mother agrees to use ER, 911, or call this office as needed. Cont (med). Gave script for _________, _____refills. Mother agrees to cont. to manage med supply, oversee administration. RTC_____.
Initial Evaluation: One Hour (Level 5 based on consultation time & length of visit)
Follow-up visits: 25 minutes (Level 4) Schedule three follow-up visits per hour,
this allows for cancels and no-shows Provide minor medical evaluations, WCC
with follow-up appointments Can be reimbursed to support salary,
medical assistant, cost of rooms and overhead, psychiatric consultation up to 8 hours per month
Mental health visit, never scheduled new patient visit
PSYCHIATRIST:
Psychiatric
Evaluation, m
ed
monitorin
g,
determinatio
n of
service need,
consultatio
n,
over see
treatm
ent
plan
Psychologist:
Psychological
Evaluation, Evaluation
for intensive services,
over see treatment,
psychotherapy plans PCP’s: ID
high risk,
depressed
youth,
supportive
counseling,
active
monitoring,
assess
somatic c/o,
G&D
Counselors: Diagnostic
evaluations, psychotherapy , treatment plan
NP with MH Training: Establish systematic
plan for identification & monitoring,
comprehensive evaluation,
supportive counseling, psychoeducation,
brief focused psychotherapy,
medication management,
establish collaborative relationships, cost
effective care
Tell me, in your own words, why you are here today
Easy visit…talk, not in trouble for anything
May try to solve some problems, make something go better
Begin with social assessment Monitor family interaction Establish boundaries, expectations of
visit
NAMI, www.nami.org
Child and Adolescent Bipolar Foundation, www.bpkids.org
Depression and Bipolar Support Alliance, www.dbsalliance.org
Depression and Related Affective Disorders Association, www.drada.org
Families for Depression Awareness, www.familyaware.org
National Mental Health Association, www.nmha.org
Suicide Prevention Action Networks, www.span.org
American Academy of Child and Adolescent Psychiatry, www.aacap.org
American Academy of Pediatrics, www.aap.org
American Psychological Association, www.apa.org
Center for the Advancement of Children’s Mental Health, www.kidsmentalhealth.org
Centers for Disease Control and Prevention, www.cdc.gov
Food and Drug Administration (FDA), www.fda.gov
National Institute of Mental Health (NIMH), www.nimh.nih.gov
A parent presents with 15 year old daughter for a WCC. During the interview the Mother states her daughter suffers from depression and has been in individual therapy for 4 months and is not getting better. The therapist recommended a physical examination. The patient avoids eye contact and gives little information, she rolls her eyes as her mother talks. During the exam you notice multiple linear scars on her upper thighs, and a 20 lb weight loss since last year although BMI is WNL. How do you proceed?
Parents of a third grade male bring him to the office for complaints academic problems. He has already repeated second grade and has failing grades half way through this year. The teacher Vanderbilt has a 4/9 score for inattention, negative for hyperactivity. Parent Vanderbilt is 7/9 for inattention and 4/9 for hyperactivity. The Parent SCAReD is 29, positive for somatic complaints and school avoidance. How would you proceed?
A 5th grade female presents for c/o intermittent abd pain. Onset was the beginning of October and this is December. Previous w/u was negative. The parents note the pain occurs from Sunday evening through Friday and has resulted in much missed school, the family is about to be fined. Mother believes child’s teacher is too “loud”, yells a lot. Mother requests a medical excuse child’s absences or class changed. They called MH but can not be seen by a psychiatrist for several months. The excuse must be from a medical provider. How would you proceed?
Brent, D., Kolko, D.( 1998). Psychotherapy: Definitions, mechanisms of action, and relationship to etiological models. Journal of Abnormal Child Psychology, 26(1), 17-25.
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