Feb 21, 2020
In this podcast, Dr. Josh Stein, an adult and child psychiatrist with PrairieCare medical group, and Joe Waller, Operations Director and a licensed graduate social worker with PrairieCare medical group, presented at Ridgeview Medical Center's Live Friday CME Series on January 10, 2020. At this event, Dr. Stein and Joe discussed different treatment levels and modalities that PrairieCare medical group is able to offer. While much of this talk deals specifically with the Ridgeview locale and PrairieCare, it is a good overview of where we are at in our day and age with child and adolescent psychiatric treatment.
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Accessing psychiatric care for our pediatric patients presents a number of challenges. There are many acronyms for our patients receiving care or in need of care. We mention this because it is important to better define these services so that we can navigate the system more appropriately for our patients.
With regard to PrairieCare, the first stage in care is the needs assessment, which really helps to define the level of care our patients will require. As mentioned, this process can be started simply by picking up the phone and calling PrairieCare's number to discuss cases and essentially immediately obtain a psychiatric consultation from Dr. Stein or his partner(s). The triage portion of this consultation is handled by a social worker, such as Joe Waller, who assesses the often complex needs of our child psychiatry patients.
Dr. Stein discusses an average, fairly typical patient he treats in the child psychiatry world. While general psychiatry looks at biologic illness, in the child psychiatry world, much of the diagnoses are quite directly linked to exposure and environment these children are actively experiencing. This particular 9 yo patient he presents to us has experienced exposure in utero, violence at home and witnessing abuse, divorce, limited paternal relationship, differences in parenting, education challenges, living environment changes, and video game overuse to placate behaviors. To further complicate matters, the patient threatens to kill himself, but does demonstrate empathy for others as well. His step-father is of SE Asian descent and the patient experiences barriers to psychotropic medication use and care due to some first generation cultural beliefs. So does this sound like something you can properly manage in the primary care clinic, let alone in an emergency department without resources?
Irritability and agitation tend to be fundamental qualities in child psychiatry. Bronfenbrenner's Ecological theory helps us understand the various systems that make us who we are. We are informed by a microsystem that spreads out from the self. the Chronosystem makes up the outer sphere and informs us based on the time and ear in which we accept things to be "the way they are". We are informed by what is happening in front of us, but also what we have experienced in the past. The Macrosystem is composed of overarching beliefs and values to help inform us as well. For instance, being gay is now accepted as who we are, as opposed to a psychiatric condition, as it was in the 1950s. The exosystem consists of economical, governmental, educational and political systems which tend to also inform us of who we are. For instance, the push for equality in these systems informs us that we are equally capable and worthy. The meso and microsystems involve family, school, peer, and religious affiliation. Finally we get to the "you" part of this system - that is defined by our biology and genetics.
ACEs are adverse childhood events. Parental issues, abuse, assault, medical concerns, etc. all tend to lead to early death from all causes. Impairments increase when ACEs are present. Carious untoward behaviors ensue, such as addiction, promiscuity and eating disorders. Therefore, positive childhood experiences are remedies for these kids, such as participation in sports or activities, having other adult figures who offer positive experiences that an otherwise positive parent would ordinarily provide. As Dr. Stein alluded to in the CDC study, the more ACEs a child has, the more risks (factors) they will take on. Overcoming periodic markers of stress in our childhood helps us to have success in future life stressors or obstacles. From positive stressors like passing a spelling test, to one's first crush on a girl or boy, to writing college essays. Then we have tolerable stressors like job loss, health problems and loss of a loved one. Next are the more dysfunctional, toxic stressors like physical abuse, living with violence, etc. Our ability to maturely handle each of these more minor, typical as well as tolerable life stressors depends on our ability to handle previous lesser positive stressors and so on. In other words, kids who have never learned how to move past and cope with these more basic stressors because of continuous toxic stressors like neglect, poor support, abuse, chemical dependency, violence and a variety of other dysfunctions, will continue to struggle. Many of Dr. Stein's patients are living in a chronically stressed state and therefore agitation and aggression is easily triggered with minimal provocation. Medication often is implemented in order to get a child to a state of being able to learn to address these markers of stress.
Stay tuned for the next chapter, where we will go through some statistics of childhood mental illness, and how we even begin to approach these issue in our patients.
1/5 of all adults experience mental illness. 20% of all youth live with a mental health condition from ages 13 to18. 70% of kids in the juvenile justice system have at least one mental health condition. At least 20% live with a serious MHD. Less than half of these kids will receive treatment that they actually need. Over 1/3 of students served by special education end up dropping out of school. Suicide is the 2nd leading cause of death between ages 10 and 24. Earlier diagnosis leads to earlier appropriate treatment for children. Approximately 160 people are directly affected by suicide, but a youth suicide will often directly affect hundreds or more.
We are doing a better job than before in schools now of recognizing mental illness. The stigma is gradually being erased and remedied. While social media can and does affect emotional well being, there is ironically an almost therapeutic or empathetic aspect to it. Dr. Stein gives the example of "meme" culture, which offers emotional context and description that is easily recognized and identified with by patients.
Kids are talking more about suicide, and there is evidence of influencing others to consider suicide as well, similar to couples experiencing divorce. Suicide will be of great concern in our suburbs and exurbs. The Native American population in particular will continue to see a rise in this for many of the reasons mentioned in chapter 1 relating to the microsystem discussed.
So what is the goal? We need to connect kids and adults with care when it is needed. An important step is referring for evaluation when we've identified there may be a problem We in the primary care or emergency department setting often are even afraid to ask some of the questions to help identify if there is a mental illness problem, because we have limited time and resources. In general though, we're doing a much better job of screening for mental illness. For instance the schools are actually really doing a great job here. However, problems arise after we've identified an issue. The question is what do we do now? We all have experienced this, right? We want to help our patients but we are challenged by limited access to mental health resources, closed clinics, limitations on the part of the psychiatrist, etc. Sometimes kids are in a vicious cycle of crisis, and crisis aversion, which gets in the way of making progress or even getting them into the system.
Stay tuned for chapter three, where we'll take a deeper dive into what we do next and what actual options we may have for our child and adolescent psych patients. And we'll immerse into the alphabet soup of acronyms in this field. So hold on and tune back in!
Acronyms are abundant in child psychology. CTSS or children's therapeutic services and supports are a great tool for helping to assess and deescalate in the home. But there are many other programs as mentioned by Dr. Stein. Outpatient treatment is of course for patients who are otherwise stable and sage, but need regular visits for therapy and support. Intensive outpatient programs (IOP) are group based therapy programs for ongoing support and transitioning. Partial hospitalization (PHP) is a service that provides care for patients who no longer need to be fully hospitalized (or inpatient care), but they receive during the day intensive therapy, and they're not actually attending their school either, but still doing classwork in the facility. PHP of course is staffed by nurses and physicians. These patients don't meet the safety needs or criteria for impatient care. And they do go home at night with self-support skills, and there is an emphasis on supporting families of the patient. Inpatient hospitalization is fairly self-explanatory and reserved for patients who are unsafe and not thriving with the other mentioned modalities. Finally, residential treatment or RTC, is provided for patients who are well-regulated on medications but still need intensive therapy. PRTF, psychiatric residential treatment facility, is a place for patients to live while they're getting intensive outpatient therapy, but not a hospital, thereby allowing for a more independence and normalcy not found in the hospital.
Residential treatment is actually very difficult to access. These are reserved for patients who are in the vicious cycle of crisis, crisis intervention by police, emergency department visits and repeating this experience over and again. Unfortunately, after inpatient care or partial hospitalization and stabilization patients can sometimes fall between the cracks and not have important outpatient ongoing care and follow-up, therefore the same dysfunctional responses to crises happen, leading the patient right back to where they were just a few weeks ago. Primary care providers must continue to advocate for their mental health patients, and this involves transparency with what was done and planned for regarding their most recent mental health hospitalization. Case management services through the county are also quite valuable for us.
So who are typical patients. Inpatient care's goal is to have a short stay, avert the crisis at hand, and deescalate to other care options. At PrairieCare, a typical inpatient stay is 7 to 10 days. Residential treatment is for children or adults with chronic suicidality, severe biologic illness sand general unsafe existence, and it offers and opportunity to build them up with better coping skills. Partial hospitalization duration of care varies, but remember it is a step down from inpatient care and often with the same physician. With intensive outpatient treatment, there aren't usually the same safety or morbidity concerns as with the aforementioned modalities. It tends to be more common in the adult population. eating disorders as an example are commonly addressed with IOP. IOPs are fairly specific services for patients. Outpatient services are classically 1 or 2 days per week. There may be resistance to this on the part of our patients, but it's important that we push for this. A lot of changes occur in teens' live on a weekly basis as opposed to an adults. 911 for crises is always available, especially when there is risk of harm to self or others. County crisis services are also helpful and available. Also, there is the option of walking in for an appointment. The medical aspect of this service at PrairieCare and Ridgeview is helpful, but so is the social work aspect. The needs assessment of patient care is paramount, and the social workers are instrumental in heading this up. They will often provide resources for specific parental and patient concerns, such as stressors from screen overuse, LGBTQ specific needs, etc. From a medical aspect, we will be supported by the psychiatrist dosing changes, titration, etc. Fast tracker is an important tool that is sponsored by DHS that is updates and provides links and recommendations to services for some's specific locale. It is updated regularly by major and some smaller institutions.
One of the issues of our day is bullying and it's abundance in society now. But it does present a unique challenge for caregivers and providers. In many cases, bullying does not represent toxic or ongoing dysfunctional stress, because many bullied kids have other healthy releases and coping mechanisms. Nonetheless, it can be quite traumatic, especially if not addressed. It is also important to understand the difference between teasing and bullying.
Dr. Stein addresses the concern for access to the system. Essentially, the number is at our disposal, and there are many modalities available to our patients. While it is wonderful to have these options, driving distance must be considered, and we as referring providers have to advocate for our patients with regard to this. Driving 50 to 80 miles round trip for an appointment is not always desirable.
How does the primary care provider address mental health during a well visit? Dr. Stein mentions screening options which will offer some talking points. Discussing social media and its inherent struggles within this subject is also important. Bottom line is that a follow-up appointment may be necessary to address lingering concerns.