Managing common mental health
problems in pediatric primary
care
Jane Foy, MD, and Larry Wissow,
MD
Goals
• Use interactive skills in the course of
routine visits to improve clinical outcomes
for children with emotional and behavioral
problems
• Develop a personalized tool-kit of
evidence based interventions for first-line
responses to common emotional and
behavioral problems
Disclosure
• No conflicts to report
• Grateful to funders and collaborators
– Duke Endowment
– National Institute of Mental Health
– North Carolina chapter of the AAP
Outline of workshop
• Lunch
– Getting acquainted
– Self-assessment
• About 2 hours to go over video clips of
interactive skills
• About 1 hour to talk about a toolbox of
broad-based treatment elements
Background/philosophy
• Pediatric practices see same range of
severity as child psychiatrists
– But distribution varies
• Many different ways to cope
– Good triage
– Develop your own skills
– Co-locate with mental health
Core needs
• Efficiently rule out emergencies
• Provide immediate relief and advice
• Develop a mutually agreeable plan for
next steps
• Stay in control of the visit and balance the
needs of this patient with the needs of
others
To meet core needs
• Core capability for any solution might be
called “alliance” with family
– Partnership, engagement…
• Data from adult primary care studies of
depression treatment
– Relationship with provider predicted
engagement and outcome
Van Os TW. J Affect Disord 2005;84:43-51. Frémongt P. Encephale 2008;34:205-10.
Why start with a focus on alliance?
• Advice alone isn’t enough
– < 50% of psychosocial concerns disclosed
– < 50% of mental health referrals kept
– < 50% of children who start mental health
treatment finish
• Evidence from psychotherapy
– Predicts outcome over and above any
specific treatment (including medications)
Elements of alliance in
psychotherapy
• Agreement on nature of problem
• Agreement on what to do (and when to do
it)
• “Affective bond” with provider
– Trust
– Optimism
– Relief
The feeling
• How many feel they can tell when the
relationship is working (or will work)?
• How do you know?
• How often are you right?
Why alliance especially with mental
health issues?
• Particularly stigmatizing
• Doubt and equivocation part of the
“illness”
• Not sure that you’re the one to tell
• Afraid to hear the answer
What builds alliance?
• Evidence that process starts with initial
interaction with office
– Image of relationship built from staff as a
whole, not just those with most contact
– Patients value flexible, open staff who can
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•
•
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pinch hit for each other
help trouble shoot problems
speed things up when needed
realize when the patient’s context has changed
Ware NC. Psychiatr Serv. 1999;50:395-400.
Pulido R. Arch Psych Nursing 2008;22:277-87.
Patient trust and practice climate
• Adult primary care patients’ trust in provider
related to:
– Physicians and staff reporting better collaboration
with each other, more autonomy, ability to
delegate to each other
• Trust then relates to:
– Attribution of influence over healthy behaviors to
provider recommendations
Becker ER, Medical Care 2008;46:795-805
Alliance building 1:1
1. Feeling heard and understood (the bond)
2. Seeking agreement on a working
formulation of the problem
3. Seeking permission to offer advice
1. Feeling heard and understood
• Heard: active listening
– Creating the illusion of taking time
– Verbal and non-verbal indicators of paying
attention
– Interventions that “co-construct” the story
• Understood: agreement on the nature of
the concerns and the highest priorities
2. Seeking agreement on a working
formulation of the problem
• Asking for permission to gather more
information
– Opportunity to open up more sensitive areas,
rule outs, emergencies
• Asking for permission to offer a preliminary
idea of the problem
– Asking if you’ve got it
– Cycling back to more questions
3. Seeking permission to offer advice
• Ready to act?
– If not, what would it take?
• What can we do now?
• What might we need to do next?
• Responding to “no”
1. Feeling heard and
understood
Shaping concerns and managing
time
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•
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Open-ended questions
Anything else
Breaking into the long story
Managing break-ins and rambling
Skills for rambling (co-construction)
1. “I want to make sure we don’t run out of
time…”
2. Summarize your understanding and ask
for additional concerns
3. Specifically ask for focus
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•
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“Which one of those is hardest?”
“Pick one of those to start with.”
Ask for a specific example
“Pick one”
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Two in the visit: skills when turn-taking
interrupted
•
Possible tactics
Shift in body language
• Acknowledge and re-direct
• Reminder of “rules”
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•
Considerations
Timing
• Status of person interrupting or interrupted
•
“Enforcing” taking turns - child
Skills when participants are
angry at each other
• Rationale
– Want to manage negative affect in the visit (and help
people move on to problem solving)
– Want to demonstrate that dialog is possible
• Several “flavors” of extreme statements
– “Black or white” statements leave no room for
discussion
– Critical comments about family members
– Set-ups involving vague, value-laden goals
Responding to “black or white”
• Characterized by “always,” “never,” or
similar words
• Point out and ask for restatement
– Be prepared if you choose to challenge the
generalization
– Alternative: ask for “something easier to hear”
Responding to “black or white”
with “say something easier”
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Common issues in agenda
setting
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•
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Parent and child/youth have different
priorities
Family priorities not same as yours’
Opportunities for additional visits are
limited
•
You really do want to accomplish more than
you have time for!
Skills for agenda setting
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•
•
•
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Making sure this process is clear to
patient/parent
Playing back the list of concerns
Asking for priorities
Getting agreement from all parties
Openly and collaboratively problem solve
about limitations on follow-up visits
2. Getting to agreement on a working
formulation
• Why ask for permission to get more
information?
• What is it that you want to know?
– Sensitive but important details
– Data related to possibly urgent treatment
needs (including overall level of function)
– What they think might be the underlying
cause
Small group task
• “Tables” for issues that sound like they fall
into broad categories of ADHD,
depression, opposition, anxiety, substance
use
Small group task
• Brainstorm most efficient ways to ask
about:
– Overall function and possible indicators of
need for urgent care
– Sensitive but possibly important information
related to the child or family
– Somatic causes
– What child/family has already thought about
as cause/underlying issue
Reports from groups
• Focus on the first 2-3 minutes worth of
questions that will help you decide where
you are going with this problem
Hint about severity/function
• Questions from “SDQ”
– Do the difficulties you mentioned distress you
(teen) or your child (younger child)?
• How much?
– How much do they interfere with life?
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At home
With friends
In school
In other activities
3. Asking for permission to offer
advice
• Summing up your thinking and checking
for agreement
– May need to cycle back to get more
information
• Do they still agree that this is something
they want to do something about?
– If no, what should be monitored, what would it
take?
Giving advice
• Rationale
– Being directive can fail even when people want help
• Anxiety, ambivalence, shame, loss of control
– Medical provider is usually not the first person in the
chain of consultation
• People come with prior ideas and opinions (about cause,
condition, treatment) that need to be incorporated
– People will accept advice they can’t follow
• Need to actively identify barriers
Asking about readiness to act
• People may be aware of a problem but not
yet ready to act on it
– The kind of advice needed depends on this
“stage of change”
– Mis-matched advice likely to be rejected
• If ready: get permission to give advice
• If not ready: what would motivate action?
What would be grounds to act?
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When you get to give advice
• Ask for permission
– Helps patients maintain sense of control
• Ask for their ideas
• Offer advice as set of choices
– Preferably include their ideas among choices
• Frame as short and long term plans
– What might help now
– What diagnostic steps to take
Asking about barriers
• Easy to skip this step in a quick visit
• Evidence suggests even motivated
patients appreciate help with logistics
• Asking allows people to think through and
get more committed to plan
• Opportunity to build alliance and anticipate
“resistance”
Responding to “resistance”
• Overall, emphasize choice and time to
discuss
• Apologize for getting ahead
• Agreeing with a twist
• What would it take?
Getting information: apologize
for “getting ahead”
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Getting information: what would
be grounds to act?
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Agree “with a twist” and inform
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First-pass evidence-based intervention:
“practice elements”
•Four clusters account for much of what is seen in primary
care
– Low mood, anxiety, conduct, attention
•There are many “evidence-based” treatments for child
mental health problems
– Though they vary in content and intensity, treatments for any one
or related condition have many features in common
– Candidates for initial treatment
(hawaii.gov/health/mental-health/camhd/library/pdf/ebs/ebs011.pdf)
Practice elements for treating childhood anxiety
Menu of “common elements”
Anxiety
Graded exposure, modeling
ADHD and oppositional problems
Tangible rewards, praise for child and parent, help with
monitoring, time out, effective commands and limit
setting, parent psychoeducation, response cost
Low mood
Child psychoeducation, cognitive/coping methods,
problem-solving strategies, activity scheduling,
behavioral rehearsal, social skills building
A personalized, evidence-based, broadly applicable toolkit
When would you use these?
• Function good, watchful waiting, mild
symptoms
• Holding pattern: delay till mental health
appointment
• Adjunct to medication–only treatment
Common elements for depression
• Psychoeducation
– Tactful and perhaps private exploration of family
history (reduce stigma, increase empathy)
Common elements for low
mood
• Environment
– Reduce stresses and increase supports.
• Think about short term changes in demands and
responsibilities for teen AND other family members
– Removing weapons, toxins, and alcohol
regardless of concern for suicidality
– Talk about high prevalence and lack of relationship
to character, strength, etc.
– Emphasize effectiveness (though slow pace) of
treatment
Common elements for
depression
• Cognitive and coping skills (your favorites)
– Normalize common life setbacks and suggest
mantras or self-talk
– Prescribe self-care (rest, good diet, exercise)
as evidence-based approaches
– Prescribe relaxation and visualization (but
may need someone else in the office to take
the time to give instruction)
– Encourage a focus on strengths – prescribe
more activities that involve these things
Problem-solving skills
• What small, achievable act would indicate
progress?
• List difficulties/tasks
– Prioritize
– Give permission to concentrate first on one
issue at a time
Behavioral rehearsal and social
skills
• Identify problem interactions that trigger
low mood or conflict
– Can they be avoided?
– Are alternative responses possible?
– Mentally anticipate and practice responses.
Medication for depression
• FDA labeled* or good evidence for teens
– Fluoxetine* (MDD)
• The “black box” warnings
– Increased thoughts not acts
– Paroxetine worst for agitation
– Benefit seems to outweigh risk
* For children 8 and older
Medication effectiveness
• Number needed to treat about 10
• Response is slow; need 12 weeks of
increased doses at 4-week intervals to
give a fair trial is see partial response
• For any treatment (med or not) continue 612 months following recovery
Common elements for anxiety
• Environment
– What real anxiety-provoking issues are
present?
• Consider asking parent privately about
undisclosed illnesses, losses, stresses.
• Are there catastrophic consequences for “failure”?
– Does the parent have an anxiety problem
also?
• Help parents minimize their own displays of fear or
worry.
Graded exposure
• Ultimately goal is mastery rather than
avoidance
• Underlying principle is de-sensitization
• Plan for gradually increasing exposure in
supportive way
– Over time exposures get longer, more direct,
less supported
Graded exposure
• Imagining or talking about the feared
object/situation
• Tolerating short exposures or looking at
pictures with lots of support
• Tolerating progressively longer exposure
in group or with coach
• Tolerating alone but with ability to get help
Modeling
• Trusted adults engage in feared behavior
or analogue
• Vocalize feelings, openly reveal their own
anxieties and coping strategies
– Normalizing caution
– Model coping and safety strategies
Medication for anxiety
• As with depression, modestly effective
• FDA approved* and good evidence
– fluvoxamine* (anxiety)
– fluoxetine* (OCD)
Summing up
• About organizational and educational
needs?
• About building alliance?
• About core treatment elements?