1. Depression and Anxiety Disorders of Children and Adolescents

2.  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

3.  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

4.  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

6.  Depression  Depression: A change in mood characterized by sadness, irritability, negativity for at least two weeks

7.  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.

8.  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

9.  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

10.  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

11.  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)

12.  Major Depressive Disorder, recurrent, severe, with psychotic features (describes individual with 8 symptoms, second episode, and believes others are able to read their thoughts)

13.  Dysthymia  Dysthymia: 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

14.  “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

15.  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

16.  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)

17.  Research: Point prevalence for adolescents with depression being seen in primary care:  GLAD-PC:II, 2007 28 28%

18.  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

19.  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

20.  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

21.  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)

22.  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)

23.  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

24. 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

25. 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

26.  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

27.  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

28.  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

29.  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

30.  Onset  Location  Duration  Characteristics (mood, thoughts, behavior)  Associated symptoms  Relieving Factors  Timing

31.  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

32.  Determine symptom severity & progression  Frequency  Intensity  Duration  Impairment?

33.  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

34.  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)

35.  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

36.  Appearance, behavior, attitude  Characteristics of talk  Emotional state, affective reactions  Awareness, insight, reasoning and judgement

37.  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!!!!

38.  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)

39.  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)

40. Thyroid: check growth and development family history, low threshold Anemia (complaints of fatigue, irritability, diet concerns): check CBC CMP: general work-up Obstructive Sleep Apnea: Noted abnormal snoring Adverse medication reaction (prescribed and nonprescribed)

41. 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)

42.  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

43.  Identify adult(s) who are available and whom the adolescent will contact  Establish reasons to contact those adults  Give emergency numbers  Determine the adults will use the emergency numbers  Establish a regular check in time with the adults and health professional

44.  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

45.  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

46.  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

47.  Cognitive Behavioral Therapy (CBT)  Medication Only (SSRI’s)  Combination Therapy: SSRI’s and CBT

48. Prudent Mental Health Services in Primary Care Enhanced Mental Health Services In Primary Care  Treatment As Usual: not acceptable

49.  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

50.  There is no incorrect answer, honesty is all that is needed  Parents become coaches  Compliance with appointments  Participate /develop realistic treatment goals  Safety Contracts

51.  Medication management plus / minus counseling from another source  Medication management and brief psycho-therapeutic intervention

52.  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

53.  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

54.  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

55.  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

56.  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

57.  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)

58.  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

59.  Concept developed by Albert Ellis  Realized he taught the same concepts to depressed patients  Studied and described the thought patterns of depressed individuals  Adapted for children  Well tested in research

60.  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

61.  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

62.  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

63.  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

64.  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

65.  Progressive Muscle Relaxation  Yoga, general exercise  Tighten Specific Muscle Groups, relax. Usually performed with the assist of a coach (CD, etc)

66.  Imagery  Visualize a safe and content memory through all the senses, picture self there. Encourage to play their own DVD in their brain

67.  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

68.  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

69. Possible SolutionsPro’sCon’s Res ult:

70.  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

71.  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)

72.  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

73.  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

74.  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

75. SSRI Starting Dose Increments: Every 2-4 weeks Maximum Daily Dose: once daily Available Doses Fluoxetine (Prozac) FDA approval to 7 years for depression 10 mg qd10-20 mg60 mg in AM 10 mg tablets 10, 20, 40 mg pulvules 20 mg/5 cc Sertraline (Zoloft) FDA approval to 6 years for OCD 12.5-25 mg qd12.5-25 mg200 mg 25, 50, 100 mg tablets Citalopram (Celexa) 10 mg qd10 mg60 mg 10, 20, 40 mg tablets Escitalopram (Lexapro) 5 mg qd5 mg20 mg5, 10, 20 mg tablets

76.  Hypomania / mania  Akathisia (physical restlessness)  Serotonin syndrome (fever, hyperthermia, restlessness, confusion)  Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)

77.  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)

78.  Not a cause of significant weight  Not addictive  Does not change one’s personality  Not a crutch

79.  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

80.  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

81.  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”

82.  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

83.  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

84.  Significant Finding: No one in the Clinical Trials Committed Suicide!!!!!!!

85.  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

86.  Evaluation, Counsel diagnostic impression, treatment options (EBT), establish goals  Risk Assessment!!!!  Safety plan.  May begin treatment with medication.  Introduce journal keeping  Plan next visit

87.  Review major symptoms, treatment options, plan, current status, compliance.  Risk Assessment  Review safety plan  Review journal for mood, events, discovery of themes  Teach relaxation

88.  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

89.  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

90.  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

91.  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

92.  Identify youth with risk factors &/or cc of emotional problems  Establish screening process  Establish 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)

93.  Provide Supportive Counseling  Establish Treatment Plan  Establish links / collaboration with mental health resources in the community  Facilitate referrals  Active monitoring: continue contact every 1-2 weeks

94.  Generalized Anxiety Disorder (everything)  Social Phobia (scrutiny)  Separation Anxiety Disorder  Anxiety Disorder NOS  Psychological Factors Affecting Medical Condition (abdominal pain, headaches)  Somatoform Disorder NOS

95.  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

96.  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

97.  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

98.  Disorder of prominent anxiety or phobic avoidance but does not meet criteria for specific anxiety disorder

99.  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

100.  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

101.  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

102.  Genetics  Environment  Trauma  Chronic Illness

103.  Cardiac Palpitations  Hyperthyroidism  Seizure Disorder  Hypoglycemic Episodes  Caffeine Abuse  Medication effect (OTC or prescribed)  Substance Abuse

104.  Tested in 7-17 years  Researched and found to be effective in primary care  Child and parent form  Few minutes to score  Measures general, separation, social phobia, school phobia

105.  Preschool=predominantly separation  School age= worries decrease for separation and focus on performance  Adolescents= worries of peer acceptance  Follows Erikson’s developmental theory

106.  Modulated by Serotonin  Effects on other neurotransmitters  Effects of long term anxiety

107.  Everyone has fear  What are your fears  Some your age fear….  Do you have those fears everyday  How do you stop them  Who do you talk to about your fears  Use OLDCART, timeline as with depression

108.  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

109.  Educate on fear  Fear is a healthy, keeps us safe  Sometimes fear gets “stuck,” that is anxiety  WE can learn to use our mind, body, world to overcome our fears  We then use our ”tools” to systematically face our fears

110.  Fear causes our body to get ready for “fight or flight”  Flight = avoidance  Fight = tantrum  Fear effects many parts of our body (eyes, lungs, heart, stomach  Avoidance helps the moment, strengthens the fear

111. THERE IS A WAY OUT!

112.  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

113.  Keep self and family unit healthy  Be a positive role model  Assist with use of tools and exposures as planned  Problem solve current problems, futuristic problems = anxiety  Be efficient with time before exposure

114.  “Flood” with exposure  Intervention for acute onset anxiety without co-morbidity (separation anxiety, school phobia)  Evaluate effectiveness in 2-3 weeks

115.  Best practice for identification, accurate diagnosis, and treatment  Patient outcomes  Appropriate setting  Neuro-chemical etiologies, effects of treatment vs. nontreatment

116.  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)

117. DescriptionCodeTotal Visit TimeCounseling Time New patient, level 39920330 minute15.5 minutes New patient,level 4 9920445 minutes23 minutes New patient, level 59920560 minutes30.5 minutes Established patient, Level 3 9921315 minutes8 minutes Established patient, Level 4 9921425 minutes13 minutes Established patient, Level 5 9921540 minutes20.5 minutes

118.  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_____.

119.  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

120. PSYCHIATRIST: Psychiatric Evaluation, med monitoring, determination of service need, consultation, over see treatment 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

121.  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

122.  NAMI, www.nami.orgwww.nami.org  Child and Adolescent Bipolar Foundation, www.bpkids.orgwww.bpkids.org  Depression and Bipolar Support Alliance, www.dbsalliance.orgwww.dbsalliance.org  Depression and Related Affective Disorders Association, www.drada.org www.drada.org  Families for Depression Awareness, www.familyaware.orgwww.familyaware.org  National Mental Health Association, www.nmha.orgwww.nmha.org  Suicide Prevention Action Networks, www.span.orgwww.span.org

123.  American Academy of Child and Adolescent Psychiatry, www.aacap.org www.aacap.org  American Academy of Pediatrics, www.aap.orgwww.aap.org  American Psychological Association, www.apa.orgwww.apa.org  Center for the Advancement of Children’s Mental Health, www.kidsmentalhealth.org www.kidsmentalhealth.org  Centers for Disease Control and Prevention, www.cdc.govwww.cdc.gov  Food and Drug Administration (FDA), www.fda.govwww.fda.gov  National Institute of Mental Health (NIMH), www.nimh.nih.govwww.nimh.nih.gov

125.  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?

126.  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?

127.  A 5 th 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?

128.  Brent, D., Kolko, D.( 1998). Psychotherapy: Definitions, mechanisms of action, and relationship to etiological models. Journal of Abnormal Child Psychology, 26(1), 17-25.  Brent, D., Emslie, G., Clarke, G., Wagner, KD., Asarnow, JR., Keller, M., Vitiello, B., Rit,z L., Iyengar, S., Abebe, K., Birmaher, B., Ryan, N, Kennard, B., Hughes, C., DeBar, L., McCracken, J., Strober, M., Suddath, R., Spirito, A., Leonard, H., Melhem, N., Porta, G., Onorato, M., Zelazny, J. (2008). Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial, JAMA, 299(8), 901-13. Brent, DEmslie, GClarke, GWagner, KDAsarnow, JRKeller, MVitiello, BRit,z LIyengar, SAbebe, KBirmaher, BRyan, NKennard, BHughes, CDeBar, L McCracken, JStrober, MSuddath, RSpirito, ALeonard, HMelhem, NPorta, G Onorato, MZelazny, J  Campo, J., Shafer, S., Strohm, J., Lucas, A., Cassesse, C., Shaeffer, D., Altman, H. (2005). Pediatric behavioral health in primary care: A collaborative approach. Journal of American Psychiatric Nurses Association, 11(5), 276-282.  Cheung, A., Zuckerbrot, R., Jensen, P., Ghalib, K., Laraque, D., Stein, R. (2007). Guidelines for adolescent depression in primary care (GLAD-PC):II. Treatment and ongoing management. Pediatrics, 120, 1313-1395.  Daviss,W., Birmaher, B., Melhem, N., Axelson, D., Michaels, S., Brent, D. (2006). Criterion validity of the mood and feelings questionnaire for depressive episodes in clinic and non- clinic subjects. Journal of Child Psychology and Psychiatry, 47, 927-934..

129.  Freeman, J., Garcia, A., Leonard, H. (2002). Anxiety Disorders. In Lewis, M. (Ed.), Child and Adolescent Psychiatry, (pp. 821-831). Philadelphia. Lippincott Williams & Williams.  Kovacs, M., (2003). Child’s depression inventory technical manual update (Rev ed.). North Tonawanda: Multi- Health Systems Inc.  March, J., Silvia S., Petrycki, S., Curry J., Wells K., Fairbank J., Burns B., Domino M.& McNulty S. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression, Treatment for adolescents with depression study (TADS) randomized controlled study. Journal of the American Medical Association, 292, 807-820.  Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html  Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism  Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 1503-1526.  Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 107-121.  Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:2, 267-279.

130.  The use of medication in treating childhood and adolescent depression: Information for the patients and families. Available on line at ParentsMedGuide.org  Walkup, J., Albano, A., Piacentini, J., Birmaher, B., Compton, S., Sherrill, J., Ginsburg, G., Rynn, M., McCracken, J., Waslik, B., Iyengar, S., March, J., Kendall, P. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 1-14.  Weller, E., Weller, R., Rowan, A., Svadjian, H. (2002). Depressive disorders in children and adolescents. In Lewis M. (Ed.), Child and Adolescent Psychiatry (pp. 767-781). Philadelphia, Lippencott Williams & Williams.  Wren, F., Bridge, J., Birmaher, B. (2004). Screening for Childhood Anxiety Symptoms in Primary Care: Integrating Child and Parent Reports. Journal of American Academy of Child and Adolescent Psychiatry, 43, 1364-1370.  Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., Laraque, D. (2007). Guidelines for adolescent depression in primary care (GLAD-PC): Identification, assessment, and initial management. Pediatrics, 120, 1299-1312.