Sunday, January 13, 2008

Screening in Practice: A Tale of Two Teenagers

As I mentioned earlier, our practice is using the PEDS, M-CHAT, PSC, PSC-Y and CRAFFT in an effort to find mental health issues.  Mostly, we were feeling that the results showed us what we already knew; some of our patients have problems, most don't and most of the ones that do have been at least referred for services. This week, I saw two patients that showed the benefits and limitations of screening. I'll start with the benefits, and end with the cautionary tale.

So, a young man in high school came in for a check-up. I have known him since early childhood have always enjoyed talking with him. He has had some challenges in his education, but is in general, one of the most upbeat and cheerful people I know, as are his parents. He was by himself, so, I walked in the room to talk with him regarding his overall health and well-being. He told me that he doing well, although school had gotten harder, and had no specific concerns regarding his health. Things were fine at home, although I noticed that one of his parents had called 6 months ago to ask about support for teens with parents with cancer. I had just decided not to push the issue with him when I looked at the PSC-Y that he had completed, showing a score of 33, well above the "at risk" level. On further exploration, I found that he was really nervous about his parent's health, given his parent's diagnosis and prognosis, and that this anxiety was affecting his schoolwork and sleep. His parents wanted him to go into therapy, but he wasn't sure it would do him any good, and he really didn't want to go on medications. We spent about 15 minutes discussing this issue, and then he brought his dad in for us to talk some more. The family left with some ideas for where to go for appropriate mental health services, and a follow-up appointment.

That's how this is supposed to work- as a stimulus for conversation to address problems before they have developed into a crisis requiring hospitalization, medications, school suspension or court involvement. The PSC-Y prompted me to push onward; as a consequence, a young man may be able access services to help him to cope with a predictable problem. The family is intimately involved in the process; nothing is done without their consent. As I left that room, I felt like Hannibal on the "A-Team", thinking to myself, I love it when a plan comes together.

Conversely, sometimes the screen doesn't find what we know is there.  I saw another teenager who is currently in a residential DYS facility, and has a significant problem with weed.   His PSC-Y was 17, indicating low risk of problems.  When I asked him about it, he said that, since going into  lock-up, he really has few problems.  I did the CRAFFT with him as well, (we are doing that in the context of a DPH contract).  He likely did meet criteria for substance abuse.  He was, however, already in treatment and the plan was for him to be seeing a counselor when he left lockup next month.  (He was in for a physical because he needed the paperwork to enroll in a new school after returning home.)  I asked his parent to check in with us after he was left lockup, to be sure that the handoff to the outpatient therapist and psychiatrist had happened.

So,the lesson here seems to be "Don't rely on the screens too much;  you still need to talk to your patients.".  The PSC-Y said to me, appropriately, situation is under control.  In reality, there is a delicate transition that could affect the apple cart on which his mental health currently sits. Screening doesn't obviate our need to pay attention to what is going on with our patients.  It does provide a trigger, that will enhance our ability to start the conversation about mental health, without, one hopes,  interfering with our ability to form relationships with children and families.  All of this is, after all, in the interest of caring for the whole child in the context of family and community.

Oh, yes, a last word about the impact of all of this on office flow.  Addressing psychosocial health in the context of well child child care for these two patients added an extra 10 minutes per patien to my day.  So far, that hasn't seemed to have backed me up any more than usual. My colleagues and I hope that it will stay that way.

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