Welcome to Children’s TIPS 7th Annual...4/7/2021 1 Welcome to Children’s TIPS 7th Annual Abigail Schlesinger MD Agenda (AM) 8:00 to 8:15 a.m. Sign into Meeting8:15 to 8:30 a.m

4/7/2021

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Welcome to Children’s TIPS 7th AnnualAbigail Schlesinger MD

Agenda (AM)

8:00 to 8:15 a.m. Sign into Meeting

8:15 to 8:30 a.m. Introduction to TiPS

Abigail Schlesinger, MD

8:30 to 9:30 a.m. Brief Behavioral Health Interventions for Primary Care Providers

Abigail Schlesinger, MD, and Colleen Gianneski, LCSW

9:30 to 9:40 a.m. Break

9:40 to 10:40 a.m. Internalizing Disorders I

Abigail Schlesinger, MD, and Kelley Victor, MD

10:40 to 10:50 a.m. Break

10:50 to 11:50 a.m. Internalizing Disorders II


11:50 – 1:00 p.m. Lunch

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Agenda (PM)

1:00 – 2:00 p.m. ADHD Medications

Rebecca Miller, MD

2:00 – 2:10 p. m. Break

2:10 – 3:10 p.m. Internalizing Disorders III


3:10 – 3:20 p.m. Break

3:20 – 4:20p.m. COVID

Justin Schreiber, DO

4:20 – 4:30 p.m. Closing Remarks

Abigail Schlesinger, MD

Learning Objectives

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Goals of Children’s TiPS• TiPS is a FREE service to help primary care clinicians(PCCs)

deliver high quality psychotropic services for children and adolescents served by Medicaid, CHIP and UPMC by providing:– Psychiatric curbside consultation Monday - Friday 9-5pm– Additional training on the use of psychotropic medication and

responding to behavioral health issues in a primary care setting– Direct consultation with patients when needed in Pittsburgh, Erie,

or telehealth with a licensed therapist and/or child psychiatrist– Facilitated referrals to community providers when

child/adolescent would benefit from additional behavioral health services

Process

PCC and TiPS child psychiatrist consult via phone

TiPS care coordinator provides resources to PCC or family, if needed virtual Evaluation with TiPS licensed therapist or child psychiatrist, if needed

Call: 1-844-WPA-TIPS(1-844-972-8477)

Talk to TiPS team member, who will gather basic information and initiate a return call from a TiPS child psychiatrist (within 30 minutes or at a time specified by PCP)

PCC has a question about psychotropic medication or a behavioral health concern

PCC obtains verbal consent & has patient information available

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SMART Choices Support for

SBIRT Implementation

• Primary Care

• Behavioral Health

• Substance Use Providers

• Schools

• Community Members

Learning Collaboratives

• Primary Care

• Behavioral Health

• Substance Use Providers

• Community Members

Train the Trainers

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Brief Behavioral Interventions for Primary Care

TiPS Conference, April 9, 2021

Abigail Schlesinger MD

Colleen Gianneski LCSW

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Your THERAPEUTIC SKILLS can improve the trip.

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Therapeutic Toolbox

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Follow-up

Non-medication Interventions

Safety Planning

Medication

Referral and Coordination

Nonmedication Skills & Intervention

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Relationship

HELLPP Skills

Assessment

Health Behavior Interventions

BH Interventions

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HELLPPP Skills

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H = Hope

E = Empathy

L 2 = Language, Loyalty

P 3 = Permission, Partnership, Plan

American Academy of Pediatrics. Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. Elk Grove Village, IL: American

Academy of Pediatrics; 2010. Updated May 2017.tClick to add text

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Common Factors Interventions: HELPCommon • Hope: Increase the family’s hopefulness by describing your realistic expectations for

improvement and reinforcing the strengths and assets you see in the child and family

• Empathy: Communicate empathy by listening attentively, asking clarifying questions.

• Language and Loyalty: Reflect what you hear; allow the patient family the opportunity to correct any misperceptions; communicate your support and commitment to help

• Permission, Partnership & Plan: Ask for permission to ask additional questions or make suggestions; partner with child and family by working together to overcome barriers and identifying achievable steps that align with the family’s motivation; Establish a plan (or incremental first steps)

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Organizing the Session

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• I understand you are here for help with your mood. Today I am going to ask questions and listen to you so that I can better understand your concerns. Then we will come up with initial goals/strategies to improve your mood.

Set Agenda

Recognize frustration/fears/anger/strengths AND instill hope

• Listen and Ask targeted questions sleep, appetite, routines, school, friends, mood, hope/helplessness

Clarify Needs(assessment, differential, safety planning)

Create clear plans

Recognize frustration/fears/anger/strengths & Instill Hope

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Empathic Statements

“This has been really difficult”

“you haven’t gotten much help with this yet”

“must be really frustrating”

Emphasize hope & foster emotional regulation

“you’ve handled difficulty things before. Remember when,,,”

“I recognize this problem and have some ideas about how to

handle it”

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Brief Behavioral Interventions by Chief Complaint

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Sluggish, Irritable, Amotivated

Avoidant, fearful, anxious

Busy Body, busy brain

Chief Complaint:

• Sluggish

• Irritable

• Amotivation

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Skill: Activation

But what exactly is behavioral activation?

Behavioral activation is based on the theory that as individuals become depressed -they tend to avoid and isolate - avoidance and isolation maintains or worsen their symptoms

Behavioral activation is a skill that can help children and teens get unstuck from negative mood spirals

Behavioral activation helps children and teens engage in mood and confidence boosting activities

Skill: Activation

How to explain activation to a child or adolescent?

• The activities we engage in make a difference and can help us feel better or can lead to feeling worse

• Focusing on activity is a great place to start! (vs thoughts or feelings/ with or without medication)

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Skill: ActivationIn contrast to coping skills for anxiety that sometimes can offer quick relief, it’s a little tricker to find skills that provide “quick wins” for kids with low/irritable mood.

Where to start?

• Start with talking about activities that they enjoyed before feeling down

• Think about other daily activities/routines that are not-so-routine anymore

• Examine sleep routines and eating habits, but don’t be generic about it (“Exercise more and eat better” will likely be ignored)

Skill: Activation

What next?

• Set realistic expectations (Think recovery from an injury – slow and steady – needs help/assistance - celebrate small success – help them identify 1st step)

• Be specific and involve the child/teen (Think SMART Goals)

• Take a team approach (Involve others – not just the responsibility of the child/teen)

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Skill: Activation

Kids

• “Pick up sticks” AM/ PM

Teens

• Fab Four

Pick Up Sticks

Supplies Needed:

• Popsicles sticks (small pieces of paper or index cards)

• 2 cups (one for AM and one for PM)

Instructions: Have child and parents make 2 lists

1. Activities that child can do by themselves

2. Activities that family can do together

Goal: Pick one activity from each cup daily

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Fab Four

Enjoy “I did it!” Active Social

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday


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Chief Complaint:

• Avoidant

• Fearful

• Anxious

Skill: Exposure

But what exactly is exposure?

Exposure is an intervention that was developed to help people confront their fears. When people are fearful of something, they tend to avoid the feared objects, activities or situations.

Although this avoidance might help reduce feelings of fear in the short term, over the long term it can make the fear become even worse. Exposure can help break the pattern of avoidance and fear.

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Skill: Exposure Exposure = Desensitize

Example: Allergy Shots

• Desensitize body’s physical reactions to

an environmental trigger by injecting a known allergen

into the body, which over time will reduce

the body’s physical reaction to that allergen

• We can explain anxiety the same way - it’s brain/body

overacting to a trigger that is perceived as dangerous. Exposures

are the “shot” that re-wires the brain and reduces the reaction over time

Skill: Exposure

Other ways to exposure to children and teens?

• Cold Swimming Pool

• Movie Theater

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Skill: Exposure

How to explain exposure to parents?

Anxiety is:

• Overestimation of risk

• Underestimation of confidence

Part of the brain where anxiety lives…

• Does not understand language (why reassurance hasn’t helped)

• Does understand behaviors (why avoidance/rescuing doesn’t help)

Exposures allow their child…

• Challenge risk in calculated way (prove the brain wrong)

• Improve confidence (they did it!)

Benefits to “riding it out”

Our brain remembers successWe learn “what goes up, will come down” by actual experience We find increased confidence with each step (I can do it!)We receive positive reinforcement

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Problems with Rescuing

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• Brain remembers the situation at its most uncomfortable point

• Take away the opportunity to learn “ride it out”

• No feeling of mastery (I can’t do it!)

• Reinforces avoidance

• Increased fear

Skill: Exposure

Kids & Teens

• Fear Ladder

• 1-2-3 Worry

• Scheduled Worry Time

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Fear Ladder Tips

• Child/teen picks the challenge!

• It’s helpful to use a fear thermometer or a Likert scale when brainstorming potential steps

• Sometimes it’s easier for the child/teen to identify the hardest step first (bullseye); Then ask… “What do you think would be a little easier than that?” (repeat)

• The child/teen stays on the step until anxiety goes down (preferably 50%)

• The child/teen discuss ahead of time what the role of the parent is (are they involved or not?)

• If you hit a roadblock – step back – don’t leave – may need to identify a “half-step” (somewhere between the last step and the next step on the ladder)

Finding the behavioral “sweet spot”

Good

Performance

Poor

Pressure, Fear, Stress

Low (Don’t care) Medium High (Freak out)

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Fear Ladder

I did it!

Step 5: Practice 1:

Step 4: Practice 1: Practice 2:

Step 3: Practice 1: Practice 2: Practice 3:

Step 2: Practice 1: Practice 2: Practice 3: Practice 4

Step 1: Practice 1: Practice 2: Practice 3: Practice 4: Practice 5:

1-2-3 Worry

This is a skill that you can teach a parent that is providing too much reassurance around repetitive worry questions.

1. Answer the question

2. Ask the child to recall the answer independently

3. Label the worry & ask the child what they/we can do to boss-back the worry

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Scheduled Worry Time

This is a skills that will help child/teen/parent set boundaries around worries.

• Pick a time to worry (can be brief)

• Decide who, what, where & when

• When a worry thought or worry talk “pops up”… practice saving it until worry time (exposure)

• Worry on purpose during that time – puts you in charge/ not your worries (exposure)

o Think / Write & Read / Record & Listen / Show (“OK”)


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Busy body, busy brain

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Chief complaint:

• Busy Body

• Busy Brain

Skill: Relaxation What is relaxation?• The state of being free from tension and anxiety

• Recreation or rest, especially after a period of work (before?)

• The loss of tension in a part of the body

• Physics: the restoration of equilibrium following a disturbance (before?)

How do I explain it to a child or teen? • Power down

• Reset

• In control

When do I do it? • Importance of practicing (think about any new skills – practice before we perform / advise against only using in-

the-moment because new things are HARD and this will likely lead to even more frustration!)

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Deep Breathing

Kids & Teens

• 4-4-8 (or 3-3-6)

• Bubble Breathing

Deep Breathing

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Progressive Muscle Relaxation

Kids

• Calm down turtle

Teens

• Making lemonade

Calm Down Turtle

• Talk about how turtles sometimes put their head,

arms and legs inside their shell

• Practice together

• Reward home practice1) Child colors 1 section of turtle every time they practice

at home

2) Child colors 4 sections of turtle every time they use the

technique to calm down

3) 4 sections = small reward / whole turtle = big reward

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Questions?

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Documents

Welcome to Children’s TIPS 7th Annual...4/7/2021 1 Welcome to Children’s TIPS 7th Annual Abigail Schlesinger MD Agenda (AM) 8:00 to 8:15 a.m. Sign into Meeting8:15 to 8:30 a.m