Tuesday, January 29, 2008

Remedy for Rosie D.: There are teams and there are teams

I had a vision today of how a team can work to keep a child with significant mental health issues healthy and functioning. That is really the vision of the Rosie D. judgment; that if we all work together, we can help families of children with mental illness to help their children grow and develop to their fullest extent. It will be quite challenging.
The vision came, of all places, at a team meeting. I hadn't seen this girl in about a year and a half; on my desk was a message announcing the time and the place of the team meeting and asking me to attend. Fortunately, I had the time to be able to go, although I had to be late to accomodate the psychiatric nurse clinician from the Massachusetts Child Psychiatry Access Project who was teaching us about the recognition and treatment of anxiety disorders in children. (In case it sounds like we do nothing but mental health in our practice- you will be happy to know that we see croup and strep throats as well.). I got to the school about 25 minutes late, and joined the team meeting already in progress.  A little (very little) background:  this was a delightful school aged child who was transferring from a private school with very strict academic standards to the public school because she was not performing well, and there was concern regarding learning issues that would be better addressed in the special education system.  On their testing, it turns out that she is a developmentally normal child with lots of anxiety issues, which came on subsequent to a lot of family issues (trauma, divorce-  I shan't go into the details, but they are impressive).   The testing showed a child who did not meet the bar for special education services, but really got anxious when faced with "time-related"tasks, who was now adapting to her new environment.
At this point in many school districts, that would be that.  School has met its obligation;  the problem in the "mental health" silo;  family and therapists should deal with it and that would be that.  At the meeting, however, we had mother, grandfather, therapist and pediatrician, as well as school psychologist, special education teacher, reading specialist, principal, classroom teacher and special education team leader.  Everyone who would be working with this child over the next year.  And we actually discussed the child:  school took off the time limits, agreed that the reading specialist would work with her through the transition, stay in touch with mother and therapist and track her through the transition year.  No one proposed medications of any kind (I was actually there mostly to assert that they weren't needed).  All left feeling that that their needs had been addressed, and that we would be watching this young lady closely for the rest of the year.  As I said before, we made a good beginning.
That's how teams are supposed to work- looking for ways in which the education system can support the family and the mental health systems, each of which can support the other.   Within the Rosie D. case is a plan to create teams like this for 10,000 children with serious emotional disturbance.  It is certainly something to aspire to;  how can we make it happen?
  • Support:  Mother and grandfather took time from work to come to the meeting;  teachers were not in classrooms, psychologists were not doing tests; pediatrician was not generating revenue (my Fellowship allows me to do stuff like this).  How much support will it take to overcome the economic disincentives to this incredibly useful work?
  • Scheduling:  We were fortunate regarding the timing the meeting.  Schools operate 7-3, doctors and therapist work on a very different schedule.  How will we make it possible to mesh these schedules?  We planning to set up a secure webconference site so that we can all get together?
  • Consensus:  Each of our professions, whether  parent, doctor, teacher, therapist, judge or probation officer,  looks at these children with different eyes.  How are we going to mediate the differences between us?  How will will we build consensus?
  • Flexibility:  CHildren don't fix into nice categories.  Supppse the official AXIS I diagnosis is "Adjustment disorder with anxiety and depression";  the difference between that and "Post-traumatic stress disorder" in some cases is razor-thin. 
This is going to be tough to pull off;  I am anxious to hear how the folks remedying the Rosie D. Case will pull it off.  I am even more anxious when I realize that the folks remedying the Rosie D. case are us.

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