1

Behavioral Health Assessment &

Treatment in Children and Youth

CWHP Training

October 4, 2017

Rick Immler MD

Goals – Increase Awareness of:

• National and Wisconsin Data on Behavioral Health Needs for Youth and those Served in Child Welfare

• Common Presenting Concerns

• Effect of Trauma and Loss

• Screening Tools

• Non-Med Evidence – Based Treatment

• CW & Prescriber Challenges & Opportunities

• Monitoring Tx: Goals and Side effects

• Key Points regarding Medication Tx

• Helpful Resources /Links

2

Acknowledgments and Disclaimer:

• Support for this Presentation from Wisconsin Medical Assistance/CCS funding through CWHP

• Content of presentation does not reflect Official Positions or Policies of Wisconsin DHS or CWHP

• This author does not endorse any specific medication or dosing regimes. Non-FDA approved use may be discussed.

• Any treatment decisions should be made in consultation with the appropriate mental health or medical professionals

• To

(Especially When We Overcome Them Together)

3

Questions that You Hope will be Addressed

Case Discussion in Small Groups(please select a challenging case and discuss

with sensitivity to privacy)

4

CCS Program – Service Array: Provider Functions per Forward Health:

• Screening and Assessment

• Service Planning: based on assessed needs of the member

• Service Facilitation: assisting the member in self advocacy

• Medication Management: increasing understanding of benefits and the symptoms it is treating/monitoring changes in symptoms and side effects

• Physical Health Monitoring: focus on ability to monitor and manage health and risks

• Individual Skill Development and Enhancement: training in daily living skills including connecting to community resources and healthcare services.

• Psychoeducation: providing education and resources about mental health and/or substance abuse issues

How Frequent is Behavioral Health Difficulty?

5

Youth Risk Behavior Survey – WI High Schools 2013

YRBS – WI High School 2013 – Past Year

• 24.6% – So sad or hopeless almost every day for two weeks => Stop doing some usual activities (female 32.9 %)

• 17.3% – Purposely hurt themselves without wanting to die

• 6.0% – Actually attempted suicide one or more times(female 24.7%)

• 7.5% – Forced, either verbally or physically to take part in the sexual activity (females 11.4%)

6

6 County CWHP High School Students

Results from High School YRBS – CWHP (2016?)

7

Mental Health Needs of Youth in FC

• Rates of emotional or behavioral disorders*

-Foster Care: 37-80%

-Community-Based: 11-25%

• Why?

-Trauma associated with abuse/neglect

-Domestic violence

-Poverty

-In-utero environmental drug exposure

-Genetic loading

-Trauma due to removal from home

(RI: and Earlier Disrupted Attachment)

14

8

15

Social – Emotional Need vs. Rx Use

9

17

18

10

Common Presenting Concerns

• Anger/Aggression

•Withdrawal/Avoidant Patterns of Behavior

• Risk Taking /Self injury/Suicidal thoughts or Behaviors

• School Refusal

• Sleep Difficulty

• Academic Difficulty

• Conflict in Primary Relationships

• Over/Under Eating

Dx -- > Rx in Foster Care

11

Effects of Trauma

• Through Our Eyes: Children, Violence, and Trauma —Introduction

• Office of Victims of Crime

• https://www.youtube.com/watch?v=z8vZxDa2KPM (7:53 min)

Trauma Trauma Trauma Trauma ---- Toxic Stress & Disrupted Toxic Stress & Disrupted Toxic Stress & Disrupted Toxic Stress & Disrupted

AttachmentAttachmentAttachmentAttachment

12

https://learn.nctsn.org/pluginfile.php/119726/mod_pcast/episode/11/Rebecca-Mataya-10.mp3

Trauma and Attachment Sensitivity

• Hypervigilance, Avoidance or Numbing

• Reactiveness -> (Freeze) Flight, Fight -> Anger

• Safety: Establish Routines and Sleep Pattern

• Depending on Age – Closeness as Tolerated/ Child Directed Play/ Listening & Validating

• Watch for Specific Triggers (and Response)

• Sensitivity to Transitions

• (foster parents & sibs, school, peers, bio family - calls and visits, environment)

13

Trauma Screening by Primary Care

• “Inquire directly about trauma, which could include child abuse, domestic violence, community violence, or serious accidents. Avoid asking the child for specific details of trauma during a brief office visit as this can be very distressing for the child, unless this is necessary to ensure their current safety.

• “Consider asking for trauma details from the caregiver instead.

• “Or ask the child a general question like, “What’s the worst thing that ever happened to you?” so that the child can be in control of their response.

• “Or ask the child about current symptoms of PTSD rather than asking for trauma details.”

VA - National Center for PTSD

14

Levels of Trauma & PTSD Screening

• General Symptom Screening• CANS – Trauma Module pages 40 – 49

• Trauma Exposure Measures• Traumatic Events Symptom Inventory (TESI – Available free

from VA)

• Trauma Exposure and Symptom Measures• UCLA Child/Adolescent PTSD Reaction Index for DSM-V

• PTSD and Symptom Measures• Child PTSD Symptom Scale (CPSS) • Trauma Symptom Checklist for Children (TSCC)

Child Adolescent Needs and Strengths –General Screening

• CANS – Pages 40 – 49 Trauma Module

• https://www.magellanprovider.com/media/11838/cans-mhmanual.pdf

15

Trauma Exposure – Child Version (from VA)

Trauma Exposure and Symptom Measures

• NCTSN: UCLA PTSD Reaction Index

(has five slides listing DSM 5 PTSD criteria)

• http://www.nctsn.org/nctsn_assets/pdfs/mediasite/ptsd-training.pdf

16

AAP Foster Parent Info on Trauma

AAP Foster Parent info on Trauma

17

18

Practice Wise Guidance on EBP

Practice Wise Guidance on EBP

19

Trauma Sensitive Therapy(Before Meds if Possible) (Before Meds if Possible) (Before Meds if Possible) (Before Meds if Possible)

• TF-CBT (Trauma Focused – Cognitive Behavioral Therapy - for Ages 5-17 with Option for Younger)

• PCIT (Parent Child Interaction Tx – Ages 2-7)

• CPP (Child Parent Psychotherapy – Ages 0-5)

•MST (Multisystemic Therapy - for JJ Ages 6-17)

•MTFC (Multidimensional Treatment Foster Care)

• Ages 12-17

• CW: Keeping Foster Parents Trained & Supported

• Also Early Intervention Foster Care

Policies to Increase Resources: Cost Benefit of EBP

•Washington State Institute for Public Policy – Children’s Mental Health

• http://www.wsipp.wa.gov/BenefitCost?topicId=5

• Estimated Benefit CBT for child trauma: = almost $22,000

• Parent Child Interaction Therapy for CW = almost $23,000

• EMDR for Child Trauma = almost $9000

•Multisystemic Therapy for SED = $2600

• DBT for JJ Youth = almost $58,000

• Functional Family Therapy ranges from $18,000 – 36,000 (depends on setting)

20

Washington State Institute for Public Policy Cost Benefit

Stretch BreakStretch BreakStretch BreakStretch Break

21

Certification and Location of Therapists

22

What is Trauma-Focused Cognitive Behavioral Therapy?

• Texas Children’s Advocacy Centers (CACs) help families impacted by child abuse with highly effective therapy.

• CACTX is on the forefront of helping children’s advocacy centers (CACs) implement innovative treatment interventions, including TF-CBT.

• https://www.youtube.com/watch?v=axsButKQYCY

Trauma Focused Cognitive Behavior Therapy

• TF – CBT is an EBP with research that it is superior in improving children’s trauma symptoms

• 8 – 25 sessions effectively improve a range of outcomes

• In addition to trauma, depressive and anxious symptoms in the child improve

• Participating parent or caregiver’s personal distress, effective parenting skills and supportive interactions also improve

23

Additional Resources for Screening, Therapy and Medication

24

PALPALPALPAL – Source for EBP and Care GuidesEBP and Care GuidesEBP and Care GuidesEBP and Care Guides

• Intended to be Resource for Primary Care

• General MH Evaluation Guidance

• List of Online Resources for Specific Disorders

• Crisis Planning Tool

• Guide for Disruptive Behaviors

• Sleep Hygiene Presentation at: http://www.seattlechildrens.org/healthcare-professionals/access-services/partnership-access-line/resources/

• Evidence Base Psychosocial Treatments (AAP)

http://pediatrics.aappublications.org/content/125/Supplement_3/S128.full.pdf+html?rss=1

PALPALPALPAL – Source for Screening ToolsScreening ToolsScreening ToolsScreening Tools

• General Eval: Pediatric Symptom Checklist – 17 (PSC – 17)

• ADHD: Vanderbilt (& Preschool Version)

• Anxiety: Screen for Child Anxiety Related Disorders (SCARED)

• Depression: Short Mood and Feelings Questionnaire (SMFQ) & Patient Health Questionnaire (PHQ – 9)

25

Anxiety Screening = SCARED

?? The Magic Bullet

26

The Meaning of Medication

• “Quick Fix” in a crisis

• Biology is to “Blame”

• Absolves Need for Change in Caretaking or Need for Psycho-Social Treatment

• Child is seen as Flawed – a Problem

• A Requirement: “I have to take it”

• Part of a collaborative effort that may reduce symptoms while the youth and caregivers work on a range of long-term solutions

What “Effect” Do these Meds Have?

27

Medication “Outliers”

• Too many:

-Child taking 3+ medications at a time

-Prescribing 2+ meds in same class >30 days

-Polypharmacy before Monopharmacy

• Too young:

-Psychotropic medications in children <5 years

• Too much:

-Dosage exceeds recommendations

• Antipsychotic meds >2 years and no diagnosis of schizophrenia, bipolar disorder, or psychosis

• No documentation of risk/benefit discussion or informed consent paperwork

Adherence to Treatment• Problems with Adherence are Common

• Higher risk if the Adolescent or Bio family Do Not Feel Heard or Respected

• Greater Risk if Change in Placement or Clinician

• Do Not Adjust Treatment until Check on Adherence (ask Client and/or Pharmacy) & F/U

• Risk of Diversion with Stimulants, Benzodiazepines or Quetiapine (Seroquel)

• Improved if Open Communication and Trust in Relationship

28

Basics of Prescribing

• Based on Partnership between Child, Parent (Caregiver) and Prescriber

• Based on Comprehensive Assessment

• Clear Informed Consent (SE & Alternatives)

• Psychosocial Therapies First or Simultaneous

• Targeted to Diagnosis using Best Practices

• Careful Balancing of Benefit versus Risk including the Unknown on Brain Development

• Start Low, Go Slow – Caution before Adding

Basics of Prescribing Continued

• 1 Change at a Time – with Time for Response

• Over Time, Adjust Dose to Minimum

• Stay Within FDA Guidelines (Dose, Dx & Age)

• Regular Follow-up for Response and Side Effects –weekly to max every three months

- Height, Weight, BMI, AIMS* and Labs**

• Awareness of Limits of Med Effectiveness

• Periodic Attempts to taper and discontinue

29

We Need Each Other! We Need Each Other! We Need Each Other! We Need Each Other! (Recommendations from AACAP)

• “The history obtained from informants should include:

• “The specific circumstances surrounding the youth’s entry into care,

• “The number of placements, the circumstances and qualities of each placement,

• “Reasons for transition from one placement to another,

• “The Youth’s response to transitions,

• “Current and longitudinal contact with parents, siblings and extended family.

• “The child welfare worker usually provides much of the information, with input from other informants, including biological and foster parents when available.”

Critical Information to ShareCritical Information to ShareCritical Information to ShareCritical Information to Share

1. Chief Concern and Goal of Evaluation

2. Who has Legal Authority

3. Consent to Treat

4. Releases For Records (CW, School, Medical, MH Treatment)

5. Assessment Tools (CANS with Trauma Section)

6. Youth Placement History and Response

7. Previous Response to Treatment

8. Background Family and Social History

9. Child/Youth Interests, Strengths and Supports

30

NonNonNonNon----Specific Meds Specific Meds Specific Meds Specific Meds for Disruptive Behavior and Aggression

• If used, choose 1 med over polypharmacy

• Specific target to treat and measure response

• Aggression is not a Dx – look for and Tx the cause with psychotherapy and behavior management training (include Caregiver)

• Although there is significant research in the use of antipsychotic medications for aggression, outside of autism, they are not FDA approved

Wisconsin ForwardHealth Prescriber Wisconsin ForwardHealth Prescriber Wisconsin ForwardHealth Prescriber Wisconsin ForwardHealth Prescriber Responsibilities for Responsibilities for Responsibilities for Responsibilities for Antipsychotic Drugs Antipsychotic Drugs Antipsychotic Drugs Antipsychotic Drugs for for for for Children 7 Years of Age YoungerChildren 7 Years of Age YoungerChildren 7 Years of Age YoungerChildren 7 Years of Age Younger

• “If the child is 7 years of age or younger and requires an antipsychotic drug, the prescriber is required to complete the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger form. PA request forms must be faxed, mailed, or sent with the member to the pharmacy provider.”

• Need Dx, BMI, Target Sx, other Rx being used, and whether the is Child Psychiatry Consultation available

31

Monitoring of Atypical Antipsychotics

1. Weight checks and fasting glucose /lipid panel roughly every 6 months (RI: Wt. more often)

2. If weight gain is severe (or rapid),respond quickly

3. Monitor Abnormal Movements at baseline and every six months (longer use, higher risk)

4. Review Neuroleptic Malignant Syndrome Risk before starting

5. Discuss dystonia risk and explain the use of diphenhydramine (Benadryl) if needed

6. RI: Add Gynecomastia for Boys

Consumer Education ResourcesConsumer Education ResourcesConsumer Education ResourcesConsumer Education Resources

32

AACAP Facts For Families

Resources for Consumers – NAMIhttps://www.nami.org/Learn-More/Mental-Health-Conditions

33

NIMH Resource for Children’s MH

Child Psychiatry Consultation Program Pilot in Milwaukee & Central Wis.

For Primary Care Clinicians

34

Crisis Prevention Plan

• Discuss Triggers

• Identify Early Warning Signs (e.g. physical signs)

• List things the Youth uses to calm themselves – write them down and encourage practice, Grow the List – Consider Mindfulness

• List External Interventions to help the Child/ Adolescent calm (what the Youth would want)

• Identify Supports – agreed upon between Youth and Caregiver

DreamsDreamsDreamsDreams for our Future Systems

• “Passport” Using Claims Data for Rx, Medical/ BH Services and Provider History for Safer Tx

• $ Support for CW & Clinician Training in EBP

• Specialty Clinic Access for Complex FC Cases

• Statewide Database allowing DCF and Medicaid to Monitor Psychotropic Use in FC

• CW Access to Support from BH Clinicians / Psychiatry

• Reimbursement to Support Collaboration of CW and Primary Care / Behavioral Health

• Adequate access and quality of MH Services for Parents / Families

35

General Resources • AAP Policy on Foster Care: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-

care-america/Pages/Fostering-Health.aspx

• Psychotropic Medication and Children in Foster Care: Tips for Advocates and Judges http://www.americanbar.org/content/dam/aba/administrative/child_law/PsychMed.authcheckdam.pdf

• UCLA/Duke University National Center for Child Traumatic Stress http://www.nctsn.org/nctsn_assets/pdfs/mediasite/ptsd-training.pdf

• Helping Foster Parents Cope with Trauma – AAP https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf

• AACAP Practice Parameter Serving Youth in the Child Welfare System: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Child%20Welfare%20Council%20Approved%20for%20AACAP%20Website.pdf

• AACAP Resource Center (for Many Dx) http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Home.aspx

• 10 THINGS EVERY PEDIATRICIAN SHOULD KNOW ABOUT CHILDREN IN FOSTER CARE https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/10things.pdf

Medication Resources • Seattle Children’s Primary Care Principles for Child Mental Health By Robert Hilt, MD Program Director, Partnership

Access Line Seattle Children’s Hospital- Version 7.1 — 2017-2018 http://www.seattlechildrens.org/healthcare-professionals/access-services/partnership-access-line/resources/

• DCF link from WiSACWIS: http://www.nlm.nih.gov/medlineplus/druginformation.html

• WiSACWIS Ohio Rx link has a nice table. (Max does may be high for some ages): http://ohiomindsmatter.org/documents/Psychotropic%20Medication%20List.pdf

• APA and AACAP Parents Med Guide – Comprehensive on ADHD http://parentsmedguide.org/

• Texas Psychotropic Medication Utilization Parameters for Foster Children – 2010 http://www.dfps.state.tx.us/documents/about/pdf/TxFosterCareParameters- December2010.pdf

• NIMH on ADHD http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml

• NAMI http://www2.nami.org/Template.cfm?Section=About_Medications&Template=/ ContentManagement/ContentCombo.cfm&NavMenuID=798&ContentID=23662

• CW Clearinghouse On Psychotropic Meds https://www.childwelfare.gov/topics/systemwide/mentalhealth/effectiveness/psychotropic/?hasBeenRedirected=1

• A GUIDE ON PSYCHOTROPIC MEDICATIONS FOR YOUTH IN FOSTER CARE – DHHS https://www.childwelfare.gov/pubPDFs/makinghealthychoices.pdf

• CHCS Resource for Youth, Families, CW and Providers of Psychotropic Medications http://www.chcs.org/media/Educational-Resources-for-Families-and-Providers_FINAL.pdf

36

Questions Please!Questions Please!Questions Please!Questions Please!

Thanks for Your Passion for Our Kids!