Friday, December 28, 2007

Rose D in Real Life: Screening in Practice

We began routine screening for behavioral and mental health issues in our office last week and I began to see the CRAFFTs and PEDS and PSC/PSC-Y forms appear on all of my "check-up" kids charts.  A few observations so far:
1)  Parents (and kids) mostly don't mind.  We haven't been hearing complaints from the parents in completing the forms, and the youth waiting in exam gowns seem to find that the form gives them something to do.  Our nurses say that they have had a few parents ask them what the questions mean on some of the forms, and we haven't run into a parent who is functionally illiterate (I am certain that that will happen, and will be embarrassing for all parties concerned).  But, in our first two weeks of screening, no push back.
2)  The PEDS generates lots of conversation, mostly not about major psychiatric problems.  The PEDS asks parents what they are worrying about in a lot of different areas, and most of their worried are about things like "intoeing" and "food texture".  Worse thing that I have found in the young kids so far is some temper tantrums, and the only referral has been for toileting issues (which, I grant you may evolve into something bigger).
3)  The PSC identified kids who we already knew were in trouble.  Most kids and parents identify a few problems, but the kid who we referred for counseling and psychiatric services earlier this year (and who is now almost ready to drop out of school) showed up loud and clear as having lots of problems on the screen.  Of course, we already knew that, so it is hardly a victory for screening.  Still, would have been worse if the PSC had not indicated the need for referral.
4)  Billing has become much more complicated.  We hae to mark many codes now with each visit.  Our office manager is checking the billing sheets to see that we are filling them out properly.  We will see if these things get paid by MassHealth without resulting in additional cost to our self-pay patients.
5)  Filing has become more complex.  There are many more bit of paper to put on rings.  Can't wait for an electronic medical record.

Anyone else have stories on screening?  Let us all know.  Also, check out the story in yesterday's Globe.  and Monday's Telegram and Gazette.  Actually, yesterday was the day of mental health conundrums, mostly outside of my EPSDT visits.  More on that another time.

Tuesday, December 18, 2007

It Shouldn't Be So Hard: A Parable from the World of Families Living With Mental Illness

Got feedback today, from a colleague who thought that, while my take on the evolving mental health system was interesting, it did not reflect the pain and anguish of those who actually engage the system. This person speculated that, perhaps, that was asking too much- that one really needed to have a child in the system to understand and be able to express that degree of pain. Maybe I am doing all that I can.
My colleague may be right. I have witnessed many families dealing with childhood mental illness over the past 17 years; I have listened to their stories, and tried to fit them into the scientific paradigm in which I have been trained. My heart has gone out to each and every one of them, and I have done all that I could think of doing to try to help them care for their child. But, to show their pain- to give voice to their frustration and grief- that may require a level of empathy and literary talent that this science-focused physician does not possess. Still, there is much to learn from stories. Let me tell one, in a HIPPA-approved and names-have-been-changed manner that may illustrate the human misery associated with these disparate systems (or non-systems) of care may engender. Give me feedback, folks- I have now enabled it to be doable anonymously.
Ruel K. is a preschool boy, known to our practice since birth.  He lives with his mother and grandmother;  his father is incarcerated for something or another.  We don't know much about his psychiatric history.  His mom was young when he was born, 16 or 17, and she has worked consistently since she dropped out of high school to have Ruel.  Mother and grandmother split shifts to provide child care;  both have described him as "a handful", "hard to manage" and "difficult" since he started to walk.  They had seen me and some of my partners for his check-ups over the years, because they had to schedule things around their work schedules.
This Monday morning, however, things were clearly worse.  Both mother and grandmother were in the office.  Ruel was poking into things as his mother tried to explain what was going on.  It was complicated;  he wouldn't sleep,  he ate when he felt like it, he sometimes ran out of the house when they weren't looking, he "talked back", he didn't mind-  he was just impossible.  I tried to get a more orderly history- what happened when- and they were just not able to sort through all of the events of the past 4 years that added up to "He is out of control".  Finally, it came out:  he had taken to hurting pets that live in the house.  His mother seemed ashamed, the grandmother hurt and confused.  Both were scared; what can you do with something like that?  How do you even admit it to your doctor?  I was a bit taken aback.  Injuring animals is one of the red flags of pediatric practice;  children may do it inadvertently, but deliberately injuring animals is unusual in an almost 5 year old.  I could only imagine what was going through their heads.  Meanwhile, I took a look at Ruel.  He looked fine, and cheerful, and said nothing when I asked him about the pets.  Even so, I knew we needed to do something.
Fortunately, they had insurance (MassHealth), so there were a few things that could be done.
First, I talked safety.  Are the knives locked?  Are there other weapons?  How do you secure the doors?  They also had considered those options;  they didn't feel that he needed to be elsewhere while we worked this out.  Then I called MCPAP.  They agreed to see him and the family for an emergent evaluation, without sending him through the ER.  They thought that the family would benefit from the Family Stabilization Program, for a more complete assessment and the initiation of both behavioral and possible psychopharmaceutical therapy.  So we made the referral and thought that was that.  (I actually went on vacation, thinking that I had successful helped these folks navigate the system).  
When I returned, I was at a meeting with our Mental Health Network, and thanked the local FST provider for helping us out with a family in need.  The provider said "Oh, right, that's the family we have been unable to get in touch with".  Surprised, I asked the family came back for a follow-up visit.  They could not understand why nothing had happened.  After a few days and a bunch of phone calls, I found massive communication breakdown in the midst of plenty of communication methods.  People from our office, the MCPAP office and the FST office were getting either grandmother or mother on either a cell phone or a land line; the family didn't understand how the MCPAP and FST programs differed, and why they needed those programs when they had a perfectly good pediatrician (me) who was away on vacation; FST couldn't do anything without mothers express permission and she wanted to talk to me before agreeing to anything.  I thought that I had explained how mental health issues in childhood needed both behavioral therapy and medications sometime, and that we didn't really understand the medications in young children, so we were cautious in prescribing them.  The family thought we were blaming everything on them, and may well have thought that FST was somehow connected to DSS (Child Protective Services in Massachusetts), and couldn't understand why I hadn't prescribed anything yet.  Mother had spoken with half of the people involved; grandmother had spoken to the other half, and the net result was one month of inaction.  
As the title said,  it shouldn't be so hard.
After a few hours of listening and sorting, my care coordinator and I managed to get it straightened out.  FST went out the house and started working on the behavioral plan with both the mother and grandmother.  My office and the FST program were able to push for involvement in the local HeadStart program (he had been on the waiting list).  A psychiatrist is watching with us to look at the response to behavioral therapy and ready to offer the family advice on the the role of medication.  And neither mother nor grandmother have lost their jobs, although I suspect both have added grey hair after going through this process.  A happy beginning:  I will be watching this child carefully going forward.  
What are the lessons from this parable?
1)  Communication is everything.  I think that I gave some idea of how confusing the process got in this relatively simple interchange.  The more people involved in the interchange, the more likely miscommunication becomes.  There was no-one in this story trying to block the initiation of treatment;  the system did that for us.
2)  Persistence pays off. The flip side of that is "It is real easy in such a system to give up".  Families need to be supported through the process, with more than a phone number on a slip of paper.
3)  Families get put off by systems.  To the family, these systems we have build (MCPAP, FST, etc) all look the same, sort of, and they need a road map or a native guide to find their way through it.  In this case, I had the time, energy and a care coordinator to do that.  How do we build a system where everyone has a sherpa to climb the Himalaya of mental health care?

Monday, December 17, 2007

Looking at the World through Rosie D. Glasses

It is beginning. Screenings are being done by pediatric practitioners across the Commonwealth even as we speak. (Want to try one? Click here)  If your child screens positive, then you and your child's pediatric practitioner will have a chat, in which he or she will suggest referral to mental health resource.   And then what?  Why, your child will receive treatment.  At which point most parents will say,  "Do we have to receive treatment? What kind of treatment?  What are the risks and benefits?  Are we talking pills, or therapy?  Will my child need to lay down on a couch or go to hospital?"  
All reasonable questions.  The first one is the key-  no one can force you or your child to enter therapy or take medications.  Parents always have to right to ask questions.  As far as the other questions go, your practitioner may not have a good answer.  Why?  In part, because our current system of mental health care is not set up to let us know what is going on inside.  In many instances, we actually don't have a clear idea of which therapeutic intervention works best.  Finally, because the "system" "carves out" mental health services for the medical care system, without always allowing for the free flow of information between the providers of physical health and the providers of mental health services.
For most families, this is the frustrating part.  When a physician identifies a "problem", most people want there to be a solution.  In this case, the solution is often to send you and your child from a practice with which you are comfortable to a stranger:  an agency, a counselor (talk-therapist), a psychiatrist (physicians, licensed to dispense medication); or a family therapist, who wants to meet with you first and then your child. (By the way, check out this cool site that lets you search the resources available in Worcester County).   The wait for this initial visit can be 2-3 weeks (0r 6-8 weeks), during which time you are guessing about what to do next.  When the visit happens, you tell the story again, and so does your child.  You may wish that the mental health provider had some of the background, the sense of "how you got to this point?".  After a while (1-3 visits), the clinician will develop a "formulation" of the problem, and suggest a mode of treatment.  Sometimes, that information will get back to your primary care practitioner, completing the loop that began with screening and giving your practitioner enough information to tell you what will happen next.
 So, to figure out what is going on after a positive screen, it may well take 3-4 months to even begin your treatment.  Long time to wait to address the problem detected by the now recommended screening.  What are we going to do about this?
1)  In the words of Douglas Adams, DON'T PANIC!  The system is creaky, but it can work, with a bit of patient (or impatient) advocacy.  
2)  As a parent, you can encourage the various parts of the system to work together.  Give permission for the various components of the system to talk to each other.  
3)  Ask questions about the things that they are telling you.  Remember always to ask each person "What do you think is going on?  What do you think we should do about it?  How long do you think it will take to change or get better?"  I can almost guarantee that different people will give you different answers.  Somewhere within those answers is likely to be the truth.
4)  Find support.  The Parent-Professional Advocacy League is a good place to start-  they know a lot about children with mental health, and have a lot of parents in their system.  In Massachusetts, the MCPAP program may also be helpful;  ask your PCC for a referral.
5)  Lobby for change:  In my mind, co-location and home-based services is probably the best ways to get services more quickly to children and youth- ask if your health plan covers those services.  If not, well-  that's tomorrow's story.
Rosie D. is a beginning.  More to follow.

Friday, December 14, 2007

Wrapping Around Rosie D: Communities of Care

I got to hear Peter Metz talking about Communities of Care today, which is the Massachusetts version of the Systems of Care approach to care. This is a family-centered approach to managing child-mental health issues. He summarized the philosophy of his program with three statements about the role of families in providing the service:
  • Voice and Choice
  • Nothing About Us Without Us
  • No Shame, No Blame
The key to his program is having Family Partners and Care Managers. He feels that a large part of the problem is engagement, and that the parent parents are the key to the process. The next step is helping the families to convene a team to address the child's needs at many levels, and to address all of the family needs as they are moving through the system. The team makes a plan, monitors the plan and works with the family to make the plan work for them. There are some "flexible funds" to allow the family to fill in the gaps and provide the care. In-home respite care is a really important part of what is going on.

His program also did system level interventions, beyond the 50 kids who got intensive care management as part of his program. School commitments, PPAL, collaborative groups- Worcester Communities of Care has been involved in all of those things. He apologized that the pediatric community was not included on his slide, but I think that his slides reflected the reality that the pediatric community has not done a good job of partnering with the mental health system.

His evaluation has had some problems: the evaluation used a comparison group that was selected in a different manner and there were a lot of gaps in the follow-up data. (50-75% compliance on the various instruments). Still, the CoC kids did well, and the program has been morphed in the MBHP program Coordinated Family-Focused Care currently being piloted in 5 cities. (Soon to be rolled out throughout the State).

They also do a Training, Consultation and Coaching (TLC) program to bring state-agencies around to do more strength-based, family-driven work, working with lots of agencies around the state.

Finally, there is the collaboration with the Court System through the CMCC Youth and Families Center, located in the North and South Counties, that are partnering with the State to to work with children who are court involved and see if we can work with children with mental illness to keep them out of lock-up with intensive services. The effort is new, and is working its way through the system.

Hard to type while so much information is being presented. You really had to be there. Nice work, Peter.
Please note that these notes reflect my understanding of what was said, and likely reflect my biases and my hidden agendas, which are often hidden even from me. Please let me know if I have misunderstood what is going on- the nice thing about blogs is that you can edit and correct them.

Discussion in the Blizzard: A Day Off the Blog

It snowed yesterday in New England;  I didn't get this posting out in time.   This is not new; I had some thoughts that I used in a conversation with a number of families, and I formed them into a handout:  
10 things parents should know before seeking a diagnosis of ADHD
  • Your child is a wonderful person, with a unique way of looking at the world. 
  • AD/HD is a disorder only insofar as it interferes with your child’s ability to function in society.
  • People with AD/HD do not have short attention spans; they simply do not know to what they should give priority. They pay attention to everything.
  • There is no “test” for AD/HD; it’s a clinical diagnosis based on history, and the diagnosis is only as good as the history on which it is based.
  • Diagnosis and treatment should be separate things.
  • No one can force you to give medications to your child.
  • AD/HD responds well to limits and reinforcement- 504 plans can be very useful
  • Stimulant medications make everyone more focused. Even you.
  • Children grow and develop, even with AD/HD.
  • There is little evidence to support using two psychotropic medications to treat AD/HD in children, and none to support using three.
I would be interested in your thoughts, pro and con.  Let me know.

Wednesday, December 12, 2007

DMH and Rosie: What are they saying?

Today, I attended a meeting sponsored by the Department of Mental Health where they featured Joan Mikula from the Department of Mental Health talking about the implications of the Rosie D. case for children's mental health care in the Commonwealth. I'm taking notes on-line, because I am experimenting with this form of commentary. The talk was coupled with a talk of "restraint prevention", which is an interesting issue in it's own right. But, back to Joan: She wanted to make sure that the agencies are aware of the implications of Rosie D. for inpatient and residential services.

Her key points:
  • These change stems from the loss of a lawsuit by the Commonwealth.
  • The lawsuit requires the Commonwealth to spend $200-460 million dollars on the remedy, and it will affect all aspects of the mental health system.
  • The expectation is that the need for inpatient services over time will decrease, as we start intervening earlier, and putting new community supports in place.
  • Her fear is that we will create a new silo.
  • What we want is to create a new level of collaboration with community-based services to get children into services.
She sees this as a tremendous opportunity, that will require a new and unprecedented level of collaboration between families, doctors, mental health workers and the rest of the system.
The process is this:
Primary care doctors: Screen and refer. (MCPAP for assistance)
Mental health services: Assess with the CANS (Much training over the next few months)
A question remains: Who will assess the kids who are already in residential or inpatient treatment. The big advantage is that it will give us a common language to facilitate communication between agencies, even though it may not be the perfect tool.
Treatment: In the community as much as possible. There will be intensive care coordination, through programs like MHPSY and CFFC programs already in place. There will be a family partner to work with the child and family. There will be "crisis stabilization" services within a 7 day period to help divert children from hospitalization. There will be home based crisis services available throughout the Commonwealth, linked to the intensive care coordinators. There will be in-home behavioral health and therapy services, mentoring services for families and youth.
This is going to be major undertaking and the State is taking it very seriously: EOHHS has hired Emily Sherwood to be the quarterback of this process, and she has been out there, pulling together the team. This is our chance to really change a system that we all know has not always served our children well.
Ms. Mikula worries about many things:
  • Kids go on and off Medicaid; what then?: How do we make services seamless for kids regardless of insurance?
  • School is key: How do we coordinate this with special ed? The role of the school has to change. If more kids are in communities, more kids will be in schools.
  • Workforce issues are hugh: We will need at least 1000 new clinicians, we need hundreds of trained "family partners", the new graduates need to be trained in the techniques needed to make this work.
She ended by calling for our help, because this is our chance to finally do all of the things that we have been talking about for years.
Wraparound services: Not sure how that fits in, since it is not Medicaid-reimbursable, even though the services are the key to success. The child and family teams need to be trained in "wraparound services". She wants the outcomes to be based on performance.
Money: Where will come from? This will be a state initiative, and the State must find the money. But it is a court-mandate, which means that the legislature must find a way to make it work.
Diagnosis: The younger the child, the less clear the diagnosis. How can we decide who needs service? Those creating the new paradigm will need to think long and hard on that, as the guidelines for treatment are less clear with younger children. It will be important to tie this evolving system of care into the evolving knowledge base regarding mental health.
It was decidedly worth coming to hear the way in which the leadership of DMH has embraced the coming change.

Please note that these notes reflect my understanding of what was said, and likely reflect my biases and my hidden agendas, which are often hidden even from me. Please let me know if I have misunderstood what is going on- the nice thing about blogs is that you can edit and correct them.

Tuesday, December 11, 2007

Finding Rosie D.: Setting up a Screening Program

So now the rubber meets the road. Pediatric practices all over Massachusetts have to institute screening programs that identify children with serious emotional disturbances at all well child visits by December 31st. At our staff meeting today, we hashed out the nitty gritty of how this is going to happen, trying to keep it as simple as possible. Fortunately, the staff at South County Pediatrics are really good at this sort of thing, at least in part because they have had to put up with me doing screening of one sort or another a lot over the last 17 years.
1) We've been screening adolescents for substance abuse through the RAFFT and later the CRAFFT questions for 15 years; using standardize screening questions is pretty routine for us. In fact, the Department of Public Health is having all of their adolescent primary care sites (of which we are one) use the CRAFFT as a screener.
2) We've been passing out M-CHATs to the parents of 18 month olds for the past 2 years, and have a longstanding relationship with our local Early Intervention Center.
3) We participated in a trial of using the PEDS as a developmental screener last year; we actually decided not to use it routinely last year because we weren't convinced that it was worth the extra paperwork. But at least we know the instrument.

So, how are we going to do this?
Well, first we wanted to cast a broad net using as few instruments as possible. The M-CHAT and the CRAFFT, sadly, are focused screeners aimed at autism and substance abuse respectively. So we picked (from the list) the PEDS for kids under 5 years of age, and the PSC/PSC-Y for the older kids. Both are one-pagers, well normed and easy to score (pluses to keeping the flow going). And this way, it is just one more piece of paper (not 4 or 5 more pieces of paper). Something to be said for that.
Next, we want to minimize steps. The screener will be handed to the parents or the youth by one our our nursing staff to complete while they are waiting to be seen. The provider scores the form, discusses the results with the parent and files the form in the chart. The provider also codes for the extra procedure (in our office, I suspect that coding will be the weak link.
Finally, we wanted the protocol to be useful. The PEDS will pick up not only behavioral issues, but developmental ones as well. The PSC/PSC-Y should also help us detect school dysfunction and family stress, which are real problems, but not necessarily serious emotional disturbances. Knowing these things about our patients will help us guide them to resources.

Potential problems:
  • Lack of parent: We get lots of kids who come in without a custodial parent; they come with a friend, an aunt; if there is no parent, we can't do a proper assessment.
  • Low reading level: May take some folks a long time to complete the form, slowing down flow in the office.
  • Billing by third party payers: Families on Medicaid won't get a bill from our practice if MassHealth won't pay for it. But our families with old fashioned commercial insurance might, if thier insurance won't pay the "screening" code.
  • Too much screening: We will still do the CRAFFT and M-CHAT in addition to the other screenings, and then there is the MASQ (Medical-legal Advocacy Screening Questionnaire) that we do on behalf of Family Advocates of Central Massachusetts. It all might be too much.
  • We'll swamp our available resources: More on that later.
  • Other stuff we can't predict: We can predict that these will happen. We just can't predict what they will be.
So, here we are. Pediatricians on the verge of a nervous breakdown, finally implementing the systems of care of which we have spoken for so long. In the middle of flu season, yet. It will be interesting, for sure. And, we hope, beneficial to the children like Rosie D.

Sunday, December 9, 2007

Rosie D.: Update for Pediatricians

I'm thinking of sending this into the Mass AAP Newsletter: I would appreciate your thoughts on it's message.
Pediatricians in Massachusetts know that it is hard to arrange adequate care for our patients with mental health issues. Psychiatrists are scarce, therapists are overwhelmed, the evidence-base for the diagnosis and treatment of mental illness in children is inadequate and parents are often frustrated lack of coordination and communication between the various systems that work with this high risk population. Last year, the frustration led to a class-action lawsuit, called Rosie D.v. Romney,Patrick, in which US District Court found that the Commonwealth of Massachusetts had provided “(1) inadequate or non-existent medical assessments and coordination of needed services for children with serious emotional disturbances (SED), and (2) inadequate or non-existent in-home behavioral support services for the same group.”.[1] The court found “overwhelming” evidence from the testimony of the witnesses from both sides of the case that diagnosis and treatment is not addressed in a systematic way. Although this court was not in a position to rule on the adequacy of mental health services for children in the private insurance system, they did note that these problems were not specific to Medicaid, but endemic to all children in Massachusetts.

In developing a settlement in this case, the Court has required that MassHealth change the way in which it provides services to families at all levels. These changes will be implemented over the next two years, and will require us to practice a more comprehensive approach to childhood mental health issues than we have in the past. You will see changes in the ways in which we identify, evaluate, treat and coordinate care for children with serious emotional disturbance. The settlement calls for these changes to occur over the next two years, with the first change happening as you read this.

As of January 1, 2008, pediatricians will be required screen children with a validated screening instrument (See Table 1)

as part of the Early and Periodic Diagnostic, Screening and Treatment (EPSDT) program within MassHealth. Due to the efforts of Walther Harrison and the MCAAP’s Mental Health Task Force, we will be able to bill for the screening using the Developmental/ Behavioral Screening procedure code 96110, and will get some additional reimbursement for providing this service as part of our well-child care. Children who screen positive will require assessment and triage to one of MassHealth’s Behavioral Health Providers for further evaluation and treatment. While this may happen informally within your practice, and is certainly in line with the AAP’s new Bright Futures recommendations, the new system will require you to implement a formal screening protocol using evidence-based tools; that change will require some work on your part.

So, within your practice:

1) Pick your screening instruments: The approved instruments each have strengths and weaknesses- you and your partners need to decide what works for you. My practice has decided to use the PEDS for children under 5 years of age, except at age 18 months, when we will use the MCHAT, and the PSC/PSC-Y for the children 5 and over. For more discussion on this, check out my blog at

2) Fit the screening into your flow: The instruments need to get into the hands of parents; enlist your staff in figuring out how to make that happen. Waiting room, pre-visit mail-out, in the exam room- all have pros and cons that bear discussion with staff, as they are the ones who will make this work.

3) Know your options for referral: Unfortunately, the list of mental health providers in our area changes pretty regularly, so someone has to keep it updated. The Massachusetts Behavioral Health Partership has a great on-line directory at their website ( which often serves as a good place to start.

Over the next several months, MassHealth, working through the Massachusetts Behavioral Health Partnership and the five Managed Care Organizations that provide mental health services to our patients, will be implementing new forms of evaluation and case management. This is going to be complicated- stay tuned for further developments. More detailed information on the complexitiy of this implementation can be found in the excellent report “Implementing the Rosie D. Remedy: The Opportunities and Challenges of Restructuring a System of Care for Children’s Mental Health in Massachusetts” available at no cost from the Massachusetts Medicaid Policy Institute. ( Those with more interest should consider joining the Mental Health Taskforce (contact the at the Catherine Haggerty at the MCAAP office for more details).

Opening Blog

Welcome to my blog. I'm a pediatrician, working in a community-based teaching practice in a small town in Massachusetts, who has been given an opportunity by the Center on Medicine as a Profession at Columbia University to develop a plan to improve mental health services for children in our state. Now, having gotten this far, you are probably thinking , "Who is this guy, and why do you think you can make a difference in something as difficult as taking care of children with psychiatric issues?". Fair question, and one that deserves an answer.

1) I have been in general pediatric practice for a long time in Massachusetts, and have worked with a lot of families who have had kids with mental illness. I have watched families bang their heads (figuratively) against the walls of the mental health system, trying to find services that will help them help their child maximize his or her potential. I have been frustrated in my ability to be helpful on many occasions. I want to do better.
2) Massachusetts is ready for change, due to a new governor, new legislation in the works, and a court order to Masshealth ordering them to do better ( the Rosie D. case). Change is happening, even as we speak. The
3) Over the past 3 years, I have been working with Health Law Advocates, a statewide legal services agency, to develop a Network of advocates, parents and service providers to affect change. The Network sponsored a successful conference on Mental Health access in the Spring of 2006, and and has since served as a clearinghouse for ideas on how we can better collaborate to serve children and families. This year, we have sponsored a Mentoring and Technical Assistance Visit through the American Academy of Pediatrics by Larry Wissow MD, a child psychiatrist and pediatrician from Johns Hopkins, and are planning a series of forums in Central Massachusetts on the impending changes in the system.
4) I am very persistent. Working in Pediatrics for 17 years has taught me that change is developmental, that change takes time and that one can influence ongoing events with calm persistence and bit of luck.

So, there you have it. A quixotic quest, perhaps, but one that will be of benefit to many of my patients and their families in South Worcester County. I'll try to update this regularly, and share some of my thoughts along the way. I hope that you all comment on my quest- the good, the bad and the ugly. Your thoughts will go a long way to helping us devise a real answer to the question: "What do we want a child mental health system to look like?"

I will write more later.

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