Tuesday, February 26, 2008

2 months into the process: Where do we stand?

I added a counter to the blog last month, and it has been interesting to observe. There seems to be a steady stream of people stopping by to visit. That being the case, some of them must be disappointed to see that I haven't posted anything since the 19th. Truth be told, it's been busy. It is not that there hasn't been must to say about the state of care for children with mental health issues around the Commonwealth. It is true, however, that we have all been a little preoccupied with the flu over the last few weeks. And school vacation. And, for me, visiting kids in college.

However, I couldn't help but notice that it is approaching the 2 month anniversary of the institution of routine screening in my office and I thought it worthwhile to reflect on where we are at present.  Keep in mind that this is my experience and that of my practice;  I invite others to post their experiences as well.
1) We are not finding a lot of new stuff.   By and large, kids who arehttp://www.blogger.com/img/gl.link.gif in treatment screen themselves negative with the PSC. Kids with positive screens on the PSC and CRAFFT tend be kids that I have already identified problems. Most of those kids decline to see a therapist anyway. Frustrating. So far, all of our screening (which is a lot of paperwork) hasn't accomplished much in terms of identifying the "rest of the class". My patients from this week included a 16 y/o who I diagnosed with ADHD about 5 years ago, who decided in his junior year of high school that he didn't like the way Concerta made him feel, and that he didn't want medications. So he went off meds in the fall, with his mother's permission. He's getting C's instead of B's, but he has no interest in either therapy or different medications. My guess is that he'll bottom out and be back in to see me in the fall. The screen correctly predicted a need, but not one that I can do much about at this time. Only listen harder.
2) Screening has been normalized.   Parents and kids expect it. Foreign languages are still difficult. I had one kid the other day, a 15 year old with bipolar disorder, who didn't complete the PSC form while waiting for me to come to see him because he didn't understand that he was supposed to do it, but I haven't had anyone tell me that that we are being too nosy or that there isn't any value in "checking up" on mental health during a check-up.
3) It is still hard to make a referral.   I've already told you about Rick, the boy who needs a neuropsychologist and had a great team meeting in the beginning of the month. He's still out there, but has the neuropsych appointment scheduled for the beginning of April. His school testing showed that he has progessed over the first six months of the school year, but we still can't tell if that is adequate progress. And his attitude, the feelings of an early adolescent boy who thinks that he is stupid because he has dyslexia, grow ever more complex. I know at one level that the system is actually working for him, but at the other, I see a family just crying for something to be done. Oh, and Ruel? The young lad who was out of control, and who has had a hard time interfacing with the services in a family centered way? I got a call from a DSS sponsored day-care center the other day. This is a place that really likes working with kids whose parents have had trouble disciplining them them at home. They were looking for an immunization record to finish out their files, but I took the opportunity to ask them how this child, whose family has been seeking to medicate since September, is doing in a structured environment? According to the care provider/ therapist, he is "a bit active", but responds really well to structure and attention- they are managing him and he is learning fine without medications. The family has him seeing a child psychiatrist in March- I hope that this report reaches the psychiatrist, and indicates restraint in prescribing. How can we make sure that all of the elements of his team speak to each other in an appropriate way? I guess that the bottom line is that this stuff is hard, needs time and lots of energy. Even a well-intentioned government can't mandate those things.
All of this suggests that my earlier point remains:  Screening is the easy part;  evaluating and treating the kids and families that we have evaluated remains the problem.

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