Transcript Mental Illness in the Pediatric Population

Mental Illness in
the Pediatric
Population
Webinar: March 15, 2013
What is Mental Illness?
According to NAMI (National Alliance of Mental Illness), 2013:
• Mental illnesses are medical conditions that disrupt a
person's thinking, feeling, mood, ability to relate to others
and daily functioning.
• Just as diabetes is a disorder of the pancreas, mental
illnesses are medical conditions that often result in a
diminished capacity for coping with the ordinary demands
of life.
Common Diagnoses:
• Adolescent Bi-polar disorder
• Anxiety Disorders:
o GAD
o Panic Disorder
o Phobias
o OCD
o PTSD
• Anorexia nervosa
• ADHD
• Autism
• Fragile X syndrome
(genetic condition involving changes in part of the X
chromosome. It is the most common form of inherited
intellectual disability in boys. Fragile X syndrome can be
a cause of autism or related disorders, although not all
children with fragile X syndrome have these conditions.)
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Borderline Personality disorder
Depression
Impulse control disorder
Oppositional defiant disorder
Schizophrenia
Trichotillomania
Tourette’s syndrome
Fetal Alcohol Syndrome
Separation Anxiety
Diagnoses Authority:
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
A manual published by the American Psychiatric Association (APA)
that includes all currently recognized mental health disorders. The
coding system utilized by the DSM-IV is designed to correspond
with codes from the International Classification of Diseases,
commonly referred to as the ICD.
• DSM-5 is scheduled for release in May 2013.
Facts:
• Falls along a continuum of severity
• About 1 in 17 Americans, live with a serious mental illness
• The U.S. Surgeon General -10% of children and adolescents
in the United States suffer from serious emotional and mental
disorders that cause significant functional impairment in their
day-to-day lives at home, in school and with peers
• Over 50% of students age 14 and older, with a mental
disorder, drop out of high school—the highest dropout rate of
any disability group
• ½ of all lifetime cases begin by age 14, ¾ by age 24.6 yrs.
Facts (con’t):
• World Health Organization (WHO) - four of the 10 leading
causes of disability in the US are mental disorders.
• By 2020, Major Depressive illness will be the leading cause of
disability in the world for women and children.
• Usually strikes individuals in the prime of their lives, often during
adolescence and young adulthood.
• All ages are susceptible, but the young and the old are
especially vulnerable.
• Suicide is the 11th leading cause of death in the United States
o 3rd leading cause of death for ages 10-24 years.
• More than 90% of those who die by suicide have a
diagnosable mental disorder
• 70% of youth in juvenile justice systems have at least one
mental disorder
o at least 20% experiencing significant functional impairment
“This is a real issue
for families and
shouldn’t be ignored
because it is
uncomfortable. The
earlier it is treated,
the greater chance of
recovery.”
The Family Experience with Primary Care
Dana Markey
Program Manager, NAMI Child and Adolescent
Action Center
Consequences to Individuals
and Society when untreated:
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unnecessary disability
unemployment
substance abuse
homelessness
inappropriate incarceration
suicide
violence toward others
wasted lives
face an increased risk of having chronic medical conditions.
Adults with serious mental illness die 25 years earlier than other
Americans, largely due to treatable medical conditions.
*Untreated mental illness cost is more than 100 billion dollars each
year in the US.
Current state of treatment:
• Fewer than ½ of children with a diagnosable mental disorder
receive mental health services in a given year
• Racial and ethnic minorities are less likely to have access to
mental health services and often receive a poorer quality of
care
• Among the parents of children with serious difficulties:
o 26% reported that their child received special education
services for emotional or behavioral difficulties
o 40% reported they had contacted a general doctor about
their child’s emotional or behavioral difficulties
o 45% reported they had contact with a mental health
professional about their child’s difficulties.
Psychotropic Med txmt. per dx:
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Teens with ADHD had the highest rates at 31%
19.7% with a mood disorder like depression or bipolar disorder
Eating disorders, about 19%
11.6 percent with anxiety disorders
Youth with severe bipolar disorder (1.7%) or a neurodevelopmental
disorder such as autism (2.0%).
Reference
Merikangas K, He J, Rapoport J, Vitiello B, Olfson M. Medication use in US Youth with Mental
Disorders. Archives of Pediatric and Adolescent Medicine. Online ahead of print Dec 3,
2012.
Treatment Stats:
• Youth treated by a mental health professional were more likely
to be receiving appropriate medication as opposed to those
being treated within general medicine or other settings.
• More research is needed on medication use among children
younger than age 13.
• Most adolescent youth taking psychotropic medications have
serious behavioral, cognitive or emotional disturbances
• Among those youth who met criteria for any mental disorder,
14.2% reported that they had been treated with a psychotropic
medication
http://www.nimh.nih.gov/stati
stics/1NHANES.shtml
Populations at risk:
Concussion (hx) – for initial misdiagnosis
ACE (Adverse Childhood Experience)
Foster care (currently/past)
Hx. of abuse or molestation
Behavioral pxs at school
Any IP Psych
Family status change
Death in family (grief counseling)
New (existing) chronic disease dx
Low economic status (evidence based)
Autism
ADHD
Parental/Caregiver substance abuse (current/hx)
Domestic / Intimate Partner violence (current/hx)
Household member with Depression, Mental illness or Suicide
{gesture}, cutting, self-mutilation (current/hx)
• Household member in prison or litigation (current/hx)
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*Majority of list compiled by CM’s at MSU Peds Subspecialty Clinic
*Note the behaviors
that mirror changes
associated with an
Adverse Childhood
Experience (ACE),
Mental Illness (i.e.,
depression, anxiety)
or Sleep disorders.
ACE: Adverse Childhood Experience
The ten ACEs are (in no specific order):
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Emotional abuse
Emotional neglect
Physical abuse
Physical neglect
Sexual abuse
Drug addicted or alcoholic family member
Incarceration of a family member
Loss of a parent due to death, divorce, or abandonment
Mentally ill, depressed, or suicidal family member
Witnessing domestic violence
Five are personal — physical abuse, verbal abuse, sexual abuse,
physical neglect, and emotional neglect. Five are related to other
family members.
ACEs and health in later life
• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary
disease (COPD)
• Depression
• Fetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease (IHD)
• Liver disease
• Risk for intimate partner
violence
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Multiple sexual partners
Sexually transmitted infections
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of sexual activity
Early initiation of smoking
Adolescent pregnancy
Significant early adversity can
lead to lifelong problems:
As the number of adverse early childhood experiences mounts, so does the
risk of developmental delays (top).
Adults with more adverse experiences in early
childhood are also more likely to have health
problems, including alcoholism, depression, heart
disease, and diabetes.
ACE Questionnaire:
http://www.acestudy.org/files/ACE_Score_Calculator.pdf
What’s Your ACE Score?
• You get one point for each type of trauma.
• The higher your ACE score, the higher your risk of disease, social,
and emotional problems.
• ACE score of 4 or more, things start getting serious:
o The likelihood of chronic pulmonary lung
disease increases 390%
o Hepatitis, 240%
o Depression, 460%
o Suicide, 1,220%
“Primary care
physicians who
can help identify
potential mental
illness can save a
child and parent
years of pain.”
July 28th, 2011
AAP Future of Pediatrics Mental Health
Preconference
American Medical Association (AMA):
Guidelines for Adolescent Preventive Services (GAPS)
program in your primary care clinical setting.
Algorithm
http://www.ama-assn.org/ama1/pub/upload/mm/39/gapsmono.pdf
American Medical Association:
Guidelines to Adolescent
Preventive Services:
• From ages 11 to 21, all adolescents should have preventive
services visits that address both the biomedical and
psychosocial aspects of health.
• For some adolescents, health risk behaviors may be
interrelated.
• Adolescents who are found to engage in one health risk
behavior, consequently, should be asked about involvement
in others.
GAPS recommendations
compared with
Traditional approaches to
adolescent health care
Provider plays an important role in
coordinating adolescent health
promotion. This role complements
health guidance that adolescents
receive from their family, school, and
community.
Provider role is considered to be
independent of health education
programs offered by schools, family,
and the community.
Preventive interventions target social
morbidities such as alcohol and
other drug use, suicide, STDs
(including HIV), unintended
pregnancy, and eating disorders.
Emphasis is on biomedical problems
alone, such as the medical
consequences of health risk
behaviors (eg, STDs, unintended
pregnancy).
Provider emphasizes screening for
comorbidities, ie, adolescent
participation in clusters of specific
health risk behaviors.
Emphasis is on the diagnosis and
treatment of categorical health
conditions.
GAPS:
Traditional:
Annual visits permit early detection
of health problems and offer an
opportunity to provide health
education and develop a therapeutic
relationship.
Visits are scheduled only as needed
for acute care episodes or for other
specific purposes (eg, immunizations
or an examination prior to
participating in sports).
Provider performs three
comprehensive physical
examinations: one during early,
middle and late adolescence.
Current standards vary from as
necessary to examinations every two
years during adolescence.
It is recommended that all parents
receive education about adolescent
health care at least twice during their
child’s adolescence.
Parents are included in the health
care of the adolescent solely at the
discretion of the provider, who also
serves as the sole decision maker of
what health education topics should
be addressed with parents.
1ST Screen for Parents – begin
conversation:
http://www.aacap.org/cs/root/facts_for_families/facts_for_families_key
word_alphabetical
• Contains a multitude of 1-2 page documents regarding
many emotional, social, and psychological situations /
diagnoses.
• May print in PDF and place in waiting rooms.
Evidence-based Screening Tools:
Separate document posted on mipctdemo website with forms and
more detail:
ADHD: Vanderbilt’s
Autism: M-CHAT and CAST
Depression: PHQ-9
Postnatal Depression: Edinburgh
ODD: SDQ’s (forms for various ages)
Adolescent Screening for risk behaviors / depression:
HEADSS (Home, Education/employment, peer group
Activities, Drugs, Sexuallity, and Suicide/depression)
GAPS (Guidelines for Adolescent Preventive Services)tools
Substance Abuse: CRAFFT
Suicide: PHQ-9 or Adolescent Suicide Assessment Protocol (ASAP-20)
Referral Process:
• Insurance driven
o Go to insurance website – search for providers
• Parents given names / numbers or list to call
• Remind parents to sign waiver for consult info back to PCP
• Call on their behalf
o Makes a difference
o Inquire as to comprehensiveness of services available to pt
• Consider why the child is being referred:
o Diagnostic screening for diagnosis
o Medication management
o Counseling
• Send pertinent information
• Temporary need vs. long-term diagnosis
 Grief counseling
Primary Prevention:
• Promote awareness
• Encourage conversation with parents / teen
• Ask appropriate questions:
o (next slide)
• Early screening
• Early referral for counseling or grief support for known ACE’s:
(Adverse childhood experiences)
o Divorce
o Sexual molestation or abuse
o Bullying
o Severe trauma
o Hospitalization
o Children of deployed parent
o Foster children
Secondary Prevention:
• Identify children at risk
• Obtain referral and PA through insurance
• Verify appt. has been obtained
o Note: Some MH professionals will do the initial screening, but
not offer the counseling or behavioral services interventional
services. (based on financial reimbursements)
• Create a Registry
Tertiary Prevention and
Treatment:
• Identify conditions of co-morbidity and treat
• Provide ongoing support and open conversation for families
o Open communication and ongoing evaluation
• Provide resource information for parent-to-parent support
groups (Mental Health America website)
• Provide website links to evidence-based information (Resource
document)
• Promote continued involvement in therapy and support groups
• Coordinate care with schools
Impact of Treatment:
• Between 70-90% of individuals have significant reduction of
symptoms and improved quality of life
o combination of pharmacological, psychosocial treatments
and supports.
Emergency (Crisis) Intervention:
• Call local CMH ES – first (if non-violent to self or others)
• Individuals must be medically cleared first.
• Takes place in the ED
• App & Certs
• Not required for less than 18 yrs of age, unless emancipated
• Call insurance company for PA – usually done by ED CM or IP
facility
• Instruct parents to call the next day to ensure the insurance
company has all necessary information and check on benefits,
PA in place
• Parents must take
• Ambulance rides
• Documentation needed
Michigan Laws - Right of a Minor:
Mental Health – Inpatient Care
Mental Health Code, MCL 330.1498d
• Parents may admit for inpatient care.
• Minor may consent to limited inpatient care if 14 years or older.
IS PARENTAL CONSENT REQUIRED? Required
• A minor of any age may be hospitalized for mental health reasons if a parent/legal
guardian or agency
requests and the minor is found to be suitable for hospitalization.
• A minor of 14 years or older may request, and if found suitable, be hospitalized.
• Suitability, in either case, shall not be based solely on one or more of the following:
epilepsy; developmental delay; brief periods of intoxication; juvenile offenses; or
sexual, religious or political activity.
IS PARENTAL ACCESS TO THE MINOR’S INFORMATION PERMITTED?
Yes
http://www.michigan.gov/documents/mdch/Michigan_Minor_Consent_
Laws_292779_7.pdf
Michigan Laws - Right of a Minor:
Mental Health – Outpatient Care
Mental Health Code, MCL 330.1707
• Minor may consent to limited outpatient care if 14 years or older.
IS PARENTAL CONSENT REQUIRED? Not required
• A minor age 14 or older may request and receive up to 12 outpatient
sessions or four months of outpatient counseling.
IS PARENTAL ACCESS TO THE MINOR’S INFORMATION PERMITTED?
Provider discretion applies
• Information may be given to parent, guardian or person in loco parentis for
a compelling reason based on a substantial probability of harm to the minor
or to another individual;
• mental health professional must notify minor of his/her intent to inform
parent.
Munchausen by proxy
In MUNCHAUSEN BY PROXY (MBP), an individual falsifies or
induces illness in another person to accrue emotional
satisfaction—but this time vicariously. This is a form of
maltreatment (abuse and/or neglect) rather than a mental
disorder. Children are the usual victims and the mother is the
usual perpetrator. MBP is sometimes called "Fabricated or
Induced Illness by Carer" (FII).
• Question to myself & practice physicians
http://www.munchausen.com/
Pt. Care Transformation Model
(example):
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Currently hired by PO
Kim Roberts, MA, LLP (psychologist)
o Master of Arts and Limited License Practitioner (no PhD.)
Embedded in a PCMH
o 7-8000 clients in practice
 Works 2 full days / week
o Works mostly with ADHD
o Performs Diagnostic tests / Assessments
o Medication management
 Follow HEDIS rules
o Counseling:
 Parenting
 Cognitive
 School
 Play therapy for kids without ADHD
o Paid hourly
 Documents appropriately in EMR to substantiate billing
 Recoup of cost through office via insurance reimbursement for
services
Resource links:
(Separate document posted on mipctdemo website with slides)
NAMI (National Alliance on Mental Illness)
NAMI Michigan
Foster Care - Rights & Meds
HIPAA for minors
Resilience Trumps ACES
Resilience / Stress Questionnaire
American Academy of Child and Adolescent Society
“Facts for Families” – download
Mental Health America (resource for families and support group
locator)