Thursday, May 29, 2008

The AAP Weighs In on Hearts and ADHD: Told You They Would Fix It

New AAP Policy Statement Addresses Cardiovascular Monitoring and
Stimulant Drugs for Attention-Deficit/Hyperactivity Disorder

(Posted May 28, 2008)

The American Academy of Pediatrics (AAP) is providing an early release of a new policy statement entitled "Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit/Hyperactivity Disorder (ADHD)." This statement will be published later in Pediatrics. The AAP policy statement was developed in response to a scientific statement published by the American Heart Association (AHA) in the May 6, 2008 issue of the journal Circulation recommending that children taking stimulant medications for ADHD receive an ECG (an online version was published April 21, 2008).

The AAP does not recommend screening ECGs unless the patient's history, family history or the physical examination raises concerns. Listed below is the new AAP statement, the original AHA scientific statement, the erratum to the AHA statement, and an AAP/AHA clarification statement.

1) AAP Policy Statement on Cardiovascular Monitoring and Stimulant Drugs for AD/HD

2) AHA Scientific Statement on Cardiovascular Monitoring of children and adolescents with heart disease receiving stimulant drugs

3) Erratum to the AHA Scientific Statement on Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Stimulant Drugs

4) AP/AHA Clarification Statement on Cardiovascular Evaluation and Monitoring of Children and Adolescents with Heart Disease receiving Medication for ADHD [press release]

Wednesday, May 28, 2008

What I Learned in West Virginia: Build It From the Ground Up!

As a District CATCH facilitator for the AAP,  once or twice a year, I get to visit projects funded through the Healthy Tomorrows program of the Maternal and Child Health Bureau of your Federal Government.  The programs work well, as you will see in a soon to published article in Pediatrics.  I've been to programs in Rhode Island, Massachusetts, Idaho, Mississippi and Hawaii over the past few years-  learned much from all of them.  But somehow this visit in West Virginia, one of the poorest states in the nation, really showed me how community and common sense can do a lot of good. The CARES project has the potential to really help a lot of kids in that part of the universe, and has something to teach us as we develop collaborative efforts in the provision of mental health services in the Rosie D. Settlement.

They began by telling us about the cultural landscape (I wish that I could post their slides- it was masterfully done):

The ten values common to Appalachians which should be considered for culturally appropriate health care include:
  1. Individualism, Self-Reliance, Pride- most obvious characteristics; do things for oneself while not wanting to be beholding to others
  2. Religion- determines values and meaning to life; fatalistic outside factors (fate) control one’s life; believe things happen for a reason and will
  3. Neighborliness and Hospitality- help each other out, but suspicious of strangers
  4. Family Solidarity or Familism- family centered; responsibility may extend beyond immediate family; “blood is thicker than water”
  5. Lengths to keep from offending others; getting along is more important than letting one’s feelings be known
  6. Love of Place- never forget “back home” and go there as often as possible; sometimes stay in places where there is no hope of maintaining decent lives
  7. Modesty and Being Oneself- believe one should not put on airs nor pretend to be something you’re not or boastful; “don’t get above your raising”
  8. Sense of Beauty-displayed through folksongs, poems, arts, crafts, colorful language metaphors such as “I’m as nervous as a long-tailed cat in a room Full of rocking chairs”
  9. Sense of Humor-although seem dour, quick to laugh at themselves but do not appreciate being laughed at
  10. Patriotism-goes back to Civil War times; flag, land, relationships are important; shows up in community celebrations and festivals
-Jones, L. and Brunner, W. (2000) Appalachian values. New York, NY Berea Press

Then they told us how they wove that understanding of the culture into the fabric of their program design.  The project is called  
CARES (Coordinating Access to Resources and Emergency Services) and is a collaboration between the Department of Pediatrics at Marshall University's Joan Edwards School of Medicine /  Cabell Huntington Hospital and a variety of community and state agencies, notably the Huntington City Mission , to coordinate services for homeless children and children in foster care in Huntington, a city located on the Ohio River at the junction of Kentucky, Ohio and West Virginia.  The project hinges on two things:  an incredible Program Coordinator, who ensures that the partners collaboration happens, and the Parent Care Coordinators, who form the relationships that make the program work.  The program has been very successful in it's first year of operation, largely because of the wonderful relationship between the Clinic and the Mission.  Why is that?  Because, in the context of Appalachian culture (see above), it really all about relationship, and these folks have incorporated this into the core of their program.

What they, the Parent Care Coordinators, stressing their description of the program was that the CARES Project, if it was to work, needed people in the project to actually care about the families that they were trying to help in a real way, respecting them within the language and culture of Appalachia.  They saw their job as the key to that relationship:  they HAD to see the homeless family as a family, paying attention to what the family had to say and listening for a while before offering assistance.  Their first question was always: “Are they from this area?”, paying close attention to ties of family and land and acknowledging the courage needed for an Appalachian family to ask for help outside of kin.  They sat with families, at the mission, for hours, listening, taking notes, and emphasizing the strengths that the family brings to the relationship that is going to develop.  After working through that process, then they discuss the types of services available within the CARES project, and the relationship that could be forged with the "Medical Home" in the Primary Care Clinic.  They build on the respect afforded these families by the Mission, and tie that into a relationship that allows them to make their program happen.

One of the keys to their success has been the partner for this initial phase of the program.  The Huntington City Mission is a non-denominational Christian organization that has built a reputation for care for the Homeless of Appalachia over the last 60 years.  They are part of the fabric of the community of Huntington, and, by partnering with them, the medical folks have unbelievable access to the community.

So, what does all of this mean for the future of the Rosie D settlement?  First and foremost, it reminds us that as we are building CSAs and EMH mobile teams and Parent Partners, we absolutely MUST respect the culture and relationships that exist already within the communities of Massachusetts.  Worcester County needs to be served by a Worcester agency, if they are are to build on the relationships necessary to this work.  Second, it really needs to role out in stages.  Initially these folks were going to take on homeless and foster children at once, and their advisory board wisely set them on another course.  Finally, we need to listen the parents in order to make this work.  Sometimes that is hard, especially in the DSS involved families.  But we HAVE to do it, or the whole thing is as fleeting as the fog rolling through a West Virgina hollow.

Nice work, CARES PROJECT.  Thanks for letting us visit.

Tuesday, May 27, 2008

A Detour to West Virginia: What is Happening Out of State?

Hope that you all had a wonderful Memorial Day weekend: I did.  Family graduation, a bit of yardwork.  And then, back to reality.  For us, that has been the completion of the preparations for the implementation of an electronic medical record in our office (buy me a beer, and I'll tell you what it all means) and a 24 hour Technical Assistance visit to West Virginia, to hear about West Virginia CARES (Coor dinating Access to Resources and Emergency Services) Project in Huntington, W.V., will improve access to a medical home for Appalachian children who are homeless or in foster care.  I'll be back tomorrow with a description of how this is going in the Mountain State.

Wednesday, May 21, 2008

Webster Mental Health Forum: Speaking Truth to Power is a Lot of Fun

Today's Forum was AWESOME.  I offered both of the family speakers the opportunity to post their stories on the blog-  one's name is Brianna, and she may write something soon.  I'll be back later with my take on the event.
I'm back, it's later, and I wanted to spend a little time reflecting on today's event.  First, it was held at the Webster Youth and Family Center, which is part of "the next generation" of the wraparound providers that started with Worcester Communities of Care.  Unlike the original 
program, the Youth and Family Center does not offer "family centered" psychiatric evaluations, as depicted in the illustration taken from one of the many publications describing the process of wraparound.  The Center does, however, help many families in our Town of Webster connect to other resources within the community- mental health service agencies, schools, pediatricians and the like.  Suzanne Hannigan, who supervises the CoC programs in Worcester, Fitchburg and Webster, opened with a discussion of importance of families and professionals uniting to make the case that the system needs fixing, and that S.B. 2518 is the vehicle for the needed change.  Then Karen Penta of MSPCC introduced Judge Luis Perez, speaking of the great need for more support in the services of teens.  Judge Perez sees them in his courtroom, and spoke eloquently of the need for collaboration to help the kids and families through this incredibly difficult time.  Representative Paul Kujawski spoke of the difficulties of families who were not ready to accept mental illness as the root of their childs' problems and the need to get past the stigma of mental illness to allow the healing to begin.  All of this laid the groundwork for the main event, the stories of two families that have struggled with the system.
A grandmother spoke of Danielle, a 10 y/o with bipolar disorder who faced enormous challenges in diagnosis, treatment and school placement.  She spoke of the lack of understanding of mental illness on the part of the school system, of the incredible support that she has received from within and outside of the system.  She spoke with incredible candor about the difficult roads that families take to care for their children.
Then we heard the voice of youth.  Anxiety disorder and its discontents are no stranger to this blog, but Brianna, a 17 yr/old showed us what it feels like to be part of the problem, butting heads with the system, going to therapy, going to the psychiatrist.  She shared her experience with humility and grace and a way that reminded all of us why we are doing this.  Amazing.
In the end,  Representative Paul Kujawski became the 81st co-sponsor of S.B. 2518 in the Massachusetts House of Representatives.  That means that, once the bill gets out of Senate Ways and Means, it has the votes to pass both Houses of the State Legislature.  Thanks Representative Kujawski.   Cool beans.

A Note from the Children's Mental Health Campaign

From: Suzanne Curry
Date: Wed, 21 May 2008 14:35:40 -0400
To: Suzanne Curry
Conversation: Webster children's mental health forum
Subject: Webster children's mental health forum

Thank you for attending the Children’s Mental Health Forum in Webster today! Special thanks to Karen Penta, Christine Kroell, Meri Viano, and David Keller for organizing and hosting the event. Thank you also to our wonderful speakers: Sue Hannigan, Honorable Judge Luis Perez, Meri Viano, Marilyn XXXX, Brianna XXXXXX, and Dr. David Keller.

Thank you also to those of you who have added your organization to the Children’s Mental Health Campaign list of endorsing organizations. If you would like to add your organization to this list, and have not already done so, please click here. Also, check out our website at .

The Children’s Mental Health Campaign is stronger because of your support.


Suzanne Curry
Policy Associate

Health Care For All
30 Winter Street, 10th Floor
Boston, MA 02108
Tel: 617.275.2921
Fax: 617.451.5838
Join us in making a difference!

Tuesday, May 20, 2008

Getting the word out: Organizing from the bottom up.

Rosie D. and the Children's Mental Health Initiative have the potential to change the face of how care is delivered;  they are complicated and hard to understand.  Over the course of the last year, providers and advocacy groups have been engaged in the conversation with the various branches of state government;  with the forums that Health Care for All has been encouraging all over the Commonwealth, we are trying to engage more people in this process.  All of this is to say that organizing one of these events is a bit of work, but afterwards we will have the informed public that we need to make this all work.
I've been actively involved in the upcoming event in Webster-  I want to highlight the hard work of my colleagues in making this a success.  Back in April, a group of us were discussing the need to raise awareness of Children's Mental Health reform in Central Massachusetts.  In Boston, the buzz was that this was a "Boston-centric" issue, and we wanted to show that it is just as important to the families of Worcester County as it is the folks inside 128.  Also, we wanted our legislators to embrace the issue-  some had, some hadn't, but mostly, it seemed, because they hadn't been asked to do so.  
We decided to organize forum in the North, Center and South parts of the County.  The first two happened earlier this month, and have resulted in press coverage, public endorsements by legislators and a general sense that, once the budget gets through, this thing will pass.  The South County forum is tomorrow.  PAL and the Webster Youth and Family Center have done a great job recruiting families to talk about their struggles with the multiple systems of care of which you have heard me write in the past.  Judge Perez signed up immediately to speak- legislators who were available for earlier sessions are now bound up in the budget debate, but have sent written or verbal encouragement.  MSPCC, YOU Inc, the Boys and Girls Club and Health Care for All have all contributed to making the program happen.  The press is planning to come to hear our stories.
We had a Parent Advisory Group meeting at our office this evening, discussing Rosie D and the Child Mental Health Bill.  The parents present had a variety of different experiences with the system; all identified lack of coordination of care as one of the key problems and all saw how this led to "starvation in the midst of plenty."- a sometime surplus of resources that are not being used very efficiently.
And now:  we wait.  To see how it all plays out.

Talk to you tomorrow.

Monday, May 19, 2008


Worcester Vocational High School
Friday, May 16, 2008 5:30-8:30 p.m.
Featuring Michael Patrick MacDonald
(author of All Souls and Easter Rising) as guest speaker.
Call PAL Central Mass. at 508-767-9725(9PAL) to RSVP by May 12th.

Thanks to all who came.  Event was reportedly well attended and marvelous

Friday, May 16, 2008

Rosie D. and 5 Months of Screening: Access still takes time

I noticed that we have been mostly talking about S.B. 2518 lately, and not really addressing the changes that are now percolating through the system as a consequence of the implementation of the Rosie D. settlement.  This week has been a clinical one for me;  I have been seeing a lot of patients in the wake of my recent trip to the Pacific Ocean.  One from yesterday reminded me that while system changes are happening,  it is still difficult for families to engage the system and for the system to engage families.
Fred G. is a school-aged child in the 4th or 5th grade living with his/her grandparents, and who is having difficulty in social relationships and controlling anger.  (His/her?  Fred could be short for Frederica!)  Fighting at school, striking out at home, attacking friends physically for no good reason-  his/her  behaviors have escalated in the last year.  He/she was in for his/her annual physical back in January, and we talked about the family's struggle with these issues.  Our PSC screen scored a 33, and we had long discussions with the family regarding the need for mental health services to address the child's problems.  The problem didn't seem acute, so we didn't recommend an EMH evaluation-we gave out phone numbers and urged referral (school had done the same).   Problem identified;  problem addressed, right?  Score one of mental health screening.
Not really.
Fred came back this week, with his/her problems exacerbated and his/her family feeling at the end of their rope.  They have been working with our local "wraparound" agency-  he/she is signed up for "anger management" class starting in June, he/she has an intake assessment at a local mental health agency (with access to a  psychiatrist) starting in June and he/she hasn't been suspended from school.  The family, however, has seen his behaviors escalate, and they are worried that,  because of the family history of mental illness, this problem just can't wait until next month.  He/she pretty clearly didn't need to go through the EMH system, but this situation needs to be assessed for Serious Emotional Disturbance.  In the old days, this would be the classic dilemma:  too severe for the slow and plodding MH system, not severe enough for the "danger to self or others" standard set in the EMH system.  Still a problem in the new system:  soon we will be able to send them through the CSA either for an clinic based evaluation or a "mobile team" evaluation, but those bids have not gone out yet.  What can we do now?
I ended up called for a Family Stabilization Team, who seem quite willing to get involved with this family.  Turns out that pediatricians can call for an FST Team, even now.  In the past, FST required either DSS involvement or an EMH visit, but now families can be referred directly from the office.  They took the information, and I am hopeful that the family is being assessed as we speak.
Clearly, there is still many a slip twixt the screen and the evaluation (not to mention the effective evidence-based treatment).  We identified the problem, but we have not yet provided a smooth, family centered path to service.  The partners in this process (family, primary care, school, wraparound agency, mental health agency) are still engaged in "diadic" communication, with the family as the main conduit of information flow between the players.  We are beginning to have access to the tools (like FST) that we need to make this work, and this story is happier than it would have been five years ago.  We need tools: the rapidity of the assessment should match the family's perception of acuity, not ours,  the coordination of care still rests largely with the family who can be rapidly overrun by the problems, the diagnoses and the treatments are still not always as clear as they could be.  We have a long way to go.
By the way, the bidding for the CSA contracts begins now.  

To all interested parties:
Information has been posted on the MBHP web site regarding the procurement of the Community Service Agency (CSA) contracts, including a schedule for two upcoming bidders’ conferences. You can access this information from the home page at by clicking “CSA Procurement Information.
Additionally, all future communication regarding this procurement will be posted on this web site. MBHP will not be distributing updates via email.
Thank you for your interest in this important service.

Elizabeth O'Brien, LICSW
Regional Director
MBHP, Central Mass

Tuesday, May 13, 2008

North Central Massachusetts’ 2008 Regional Forum on Children's Mental Health

Families of youth with mental health needs met on Friday at Youth & Family Center North (356B Broad Street, Fitchburg) along with Massachusetts Representatives Flanagan and DiNatale, Dr. Lisa Fortuna, UMass Medical School Department of Psychiatry and Matt Noyes, Health Care for All as part of the The Children’s Mental Health Campaign (CMHC), a coalition of health care providers, families, advocates, educators, and consumers from across the Commonwealth who have come together to reform the mental health care system for children. Several families provided testimony and support for An Act Relative to Children’s Mental Health (SB2518) which aims to strengthen and improve the system that delivers care and services to children with mental health needs and their families.  See the story in today's Telegram and Gazette.

Cathy Sahler took the lead on organizing this, with support from lots of people:
The Joint Coalition on Health The Health Foundation of Central Massachusetts
Central Mass Communities of Care Youth & Central Massachusetts Medical Home Network
Family Center North Massachusetts Society for Prevention of Cruelty
Parent/ Professional Advocacy League (PAL) to Children
Massachusetts Families Organizing for Change – LUK, Inc.
Central Region Winchendon Public Schools
Community HealthLink CAVU
Montachusett Opportunity Council, Inc. Community Health Connections, Inc.
Spanish American Center
Wendell P. Clark Memorial YMCA
You, Inc.

Nice work, folks.

Sunday, May 11, 2008

In case you hadn't heard: From MCPAP

I was a little annoyed at the AHA the other day-  families of children with mental illness don't need more anxiety in their life, especially anxiety unwarranted by medical facts.  I was too angry to write anything about it.  Still am.  The MCPAP program sent this around.  Nice work, MCPAP.
Dear Dr. Keller,

The American Heart Association Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing issued a
statement which was published in the April 21, 2008 issue of the Journal of the American Heart Association’s periodical entitled Circulation. This statement recommended that children diagnosed with ADHD receive an electrocardiogram (EKG) to rule out heart abnormalities before beginning treatment with a stimulant medication. The statement recommends that children currently taking stimulant medication who did not have an EKG prior to treatment should get an EKG.

The article goes on to agree with Pediatrics conclusions that there does not seem to be compelling findings of a medication specific risk necessitating changes in our stimulant treatment of children and adolescents with ADHD.

According to the AACAP Practice Parameter on ADHD
( J.Am. Acad. Child Adolesc. Psychiatry, 46:7, July 2007) the rate of sudden death of children taking stimulant medication for ADHD does not exceed the base rate of sudden death in the general population. According to the AACAP Practice Parameter, no evidence currently indicates a need for routine cardiac evaluation (electrocardiography, echocardiography).

The American Academy of Pediatrics (AAP) recently issued a statement in response to the AHA recommendation. The response expresses concern about the feasibility of referring all patients with an ADHD diagnosis for an electrocardiogram given the limited quantity of cardiology specialists and technicians. The response also mentioned the occasional confusing results which may occur with electrocardiograms. Please visit the entry regarding the AHA recommendation
on MCPAP website to view a copy of the email alert sent to the AAP list serve.

The American Academy of Child and Adolescent Psychiatry (AACAP) is now reviewing this issue. We anticipate a recommendation from AACAP and perhaps, a joint statement from AAP and AACAP in the near future.

We hope that this information has been helpful to you, and we look forward to providing additional information on this topic as it becomes available.

Sincerely yours,

John H. Straus, MD
Vice President, Medical Affairs\

Barry Sarvet, MD
Medical Director

Joseph Gold, MD
Medical Director

Massachusetts Child Psychiatry Access Project

Thursday, May 8, 2008

"Our kids aren 't broken. The system is broken."

As regular readers (and to my eternal surprise, there ARE regular readers) of this blog know,  S.B 2518 is getting closer to reality.  As with all things legislative, it is not always clear how this bill will help the families with whom we work.  I thought it might be useful to look at a specific family with whom I have been working over the year, and think about how SB 2518 might have eased the pain of their struggle over the course of the last year.
The quote in the title came from the recent forum on Children's Mental Health, held in Worcester last week (when I began my sojourn into the Hawaiian rain forest), and seemed appropriate to describe Kenny B., a ten year old boy who came into to see me with his father last fall.  Ken had been diagnosed with ADHD several years ago, using the AAP protocols, and had actually done pretty well with treatment based on some classroom modifications (a 504 plan) and a low dose of stimulent medication.  Last spring, however, he started having angry outbursts at school that were very different from the sorts of behaviors he had had earlier in his life- something seemed different.  We referred his family to a behavioral therapist and a child psychiatrist, and sort of lost tract of them after that (confidentiality within the mental health community is a habit- collaborative care of families is difficult).  When I "remet" Kenny last fall, he was on a combination of five psychotropic medications, he had been suspended from school weekly since school began, he had been to Emergency Mental Health weekly since school began, and he had managed a 7 day inpatient stay, with little change in his therapy and NO discussion between the inpatient psychiatrists and any of his outpatient doctors.  On discharge, the family had been told to contact his psychiatrist, who was on vacation for 2 weeks.  So, not knowing what else to do, they came back to us, without answers, many questions, 5 drugs and all.  All of this, you can imagine, was playing havoc with his family.  Both parents worked, in daytime jobs that were located in the direction opposite of his school, therapist and pschiatrist (and this was before the gas prices had skyrocketed). 
I was suitably troubled by the situation, but realize that, in order to treat this child with serious emotional disturbance, I needed more information and help.  I sought out a Family Stabilization Team, but was told that his private insurance would not cover that service.  Weekly therapy, psychiatrists, hospitalizations and EMH were fine- just not intensive services designed to help manage children in the milieu in which they are most comfortable.  So I got releases of information to talk to everyone, and spend a fair bit of time talking to his school (very helpful), therapist (very helpful), psychiatrist (on vacation) and place of hospitalization, who send me a discharge summary with no clear diagnostic formulation and the words "r/o Asperger's" on it.  We spoke with DSS about voluntary services (none available at this time), DMH about case management (don't do Asperger's, even though I said it wasn't Asperger's) and the insurance company (that's all we can do, thank you).

About that time, he ended up in EMH again, although this time the family contacted me, and I was able to provide the admitting hospital with a more complete picture of what was going on.  
At the second hospitalization, the psychiatrist and psychologist finally figured out what had changed last spring- he has developed auditory and visual hallucinations, and his dissociation was at the root of much of his dysfunction.  He is now diagnosed into a DMH approved category, treated with more appropriate medications and the various components of his treatment team are speaking to each other.  The family knows that this is going to be a long and difficult road, but at least now they are on road, instead of careening from side to side.

How would SB 2518 have helped this family?  I looked at the 5 main points that this legislation currently addresses:
• Creates a system so that school personnel will be able to receive mental health consultation and guidance. In this case, Kenny's problems presented in school, yet school and psychiatrist never talked.  Might have helped speed things along.
• Requires insurance companies to pay mental health professionals for the time they spend on “collateral services,” or coordination of care with other important adults in a child’s life. I am currently on the Physician Advocacy Fellowship, that paid for me to explore this child's life in much more detail than I would usually have been able to.   This stuff takes time, and professional time needs compensation or it stops happening.  
• Promotes behavioral health screening for children during visits to their doctors. We had already done that-  not much impact on this case.
Creates processes to move children with mental health needs to a community based or residential program. This part of the bill would have helped in our efforts to get this child into the complex web of systems managed by DSS, DYS, DTA, DMH and DMH-  to get past the silos and into some real care.

What is missing?  I still couldn't refer him to Family Stabilization (which I believe would have done this family a world of good)  Wraparound services seem to be part of the Rosie D settlement, but not SB 2518.  Still, this bill would have made life easier for this family and for Kenny (who, by the way, is back in school now and seems to be doing well).  It is a great step forward in the provision of comprehensive mental health services to our children.  They deserve nothing less.

Monday, May 5, 2008

Blogging Live from the PAS: Promoting Mental Health

So, what would a meeting be without a little real-time blogging? If you follow the link, you will find that I have been at the PAS meeting in Hawaii for the past 5 days (I got here Wednesday for the APA Board meeting, as I joined as Treasurer this year.)

Topic Symposium: Promoting Mental Health for Pediatric Patients
Chairs: Kathi J. Kemper and Jane Foy, Wake Forest University School of Medicine, Winston Salem, NC.
Featuring Jim Perrin, Larry Wissow and
Scott Shannon.

Pediatricians are increasingly faced with patients who have significant mental health concerns. Given the shortage of child psychiatrists, pediatricians are eager for additional training in communication skills during these challenging encounters; an algorithm to guide an approach to evaluation, health promotion and treatment; and effective strategies to promote mental health. This session will focus on the algorithms newly developed by the AAP Task Force on Mental Health; an interactive approach to enhancing communicating skills; and practical guidance on ways to promote mental health based on lifestyle choices and natural therapies.
Target Audience: Clinicians, trainees, administrators and medical educators interested in mental health, communication skills, and complementary medicine.
Program developed by the AAP Provisional Section for Complementary, Holistic and Integrative Medicine; AAP Task Force on Mental Health; APA Special Interest Group for Integrative Medicine; Society for Adolescent Medicine and the Pediatric Academic Societies.

Please note: This is what I heard, which may or may not reflect what was said. Larry, Kathi, Jim and Scott are encouraged to correct me in the comments sections.
Kath Kemper chaired the meeting, opening with the epidemiology- anxiety is very common. Her take home message is that "You can do it. We can help".
  • Communications skills can health.
  • Promoting physicial health can promote mental health.
  • You already know how to do this.
Jim Perrin told us that the Academy does not yet have it's algorhythms already identified, but that they will do so later. He then spoke of the algorhythms that are going to come, and how they are appropriate for our practices. Primary care is a good place for this: we have the relationships, we understand chronic diseases and we are uses to intervening at multiple levels. He acknowledges that there are time constraints and payment issues that constrain access to services, and that collaborative care is really hard to do.

The AAP Mental Health Task Force has three goals:
1) Facilitate system change
2) Build confidence
3) Incremental system change.
System change: He feels that there are examples of success in system change: NC encourages co-location of mental health and physical health services( they apparently allow treatment without a diagnosis- what a cool idea!) , Massachusetts has the MCPAP (we are a national model after all), Arizona (tele-psychiatry consultation), New York (skills training) and South Carolina (routine screening for child MH problems and family distress).
The task force has given us the Chapter Action Kit to encourage collaboration within the community, and negotiations with insurers and business leaders at the national level.
Building confidence: Working on policy statements about what the pediatrician should be doing, with new competencies and changes to the residency training process. ADHD was the low hanging fruit: depression, anxiety, substance abuse are all harder. The chronic illness model is likely to be the way to go. You need a plan in place, with close follow-up.
Practice change: Algorhythms are still under development, and toolkits will happen. There will be decision support, and the toolkit will include both proprietary and non-proprietary items. Mental Health Competencies of the Care of Children and Adolescents will have some Task Force Reports, one on models of care and one on clinical care. There will likely be some changes in the screening recommendations, that emphasize functional outcomes and family diagnosis.

Larry Wissow spoke about practical paradigms in primary care. The medical paradigm says "make a diagnosis, then prescribe a treatment". In mental health, kids often don't fit neatly into a specific diagnosis. Even when you have a diagnosis, parents have many preconceived ideas about what they want, and that forcing treatment doesn't work. He likes to think about the therapeutic relationship, and the ways in which the therapeutic relationship allow you to influence behavior change.

So what do the patients expect: Parents of children with behavior problems don't believe that they are effective change agents, and don't see the pediatrician as the place to go. Kids are not used to having a role, and they usually have their own agenda of the visit. Doctors are concerned that they with be presented with insoluble problems, that take a long time to discover that you can't resolve. Larry then talked about the training program that he rolled out in Worcester, to show that it works. Key points:
1) Find a common agenda: That means talking to parent and child, and getting them to enlist them in a common set of rules.
2) Respond to negative emotions between parent and child: That means empathy without taking sides and focusing on the process, trying to get out of the middle and reframing this to be more goal oriented.
3) Focus on the problem: Check back with the family while you are in progress. People want treatment for the problem that brought them in.
Ideas: Take a "generic" approach. Think about how we approach rashes. Identify the emergencies, try something that is evidence based and follow-up. Hawaii has done some cool stuff on evidence-based stuff. Bright Futures will have some links to the evidence for treatment.
Remember, the family is the patient.

Scott Shannon is talking about lifestyle and natural therapies. Five Interventions for Pediatric Mental Health. He is not a normal psychiatrist. He sees this as a pyramid of care: Pharmacology is the last resort. We are practicing way out in front of the evidence base.
He proposes five things to worry about:
Look at sleep, exercise, omega fatty acids,

Sleep: Poor sleep is a barometer of later mental health risks. Sleep quality is a pretty good indicator of stress. When kids sleep less, they are grumpier and they don't do as well. We sleep 20% less than we did 100 years ago. This is a problem. Happens in ADHD- watch for it before you medicate.
  • Remove media from the room.
  • Stable routine, limit screen time
  • Reduce light and noise.
  • Eliminate caffeine. (finds this a lot)
  • Aromatherapy, hot baths, calming music
Exercise: Moderates stress- works as well as Zoloft, and lasts longer. Exercise doesn't have a black box warning. Also helps with the obesity issues.
  • Family fitness is a good thing.
  • TV free weekends. (Limiting screentime makes then more active)
  • Find seasonal activities.
Omega-3 essential fatty acids: Seems to be good for what ails you. Profound anti-inflammatory illness. Crucial is neuronal development. Seems to affect most chronic illness. Supplementation seems to help all diagnoses: depression and borderline PDO, among them. Minimal side effects.
  • Minimize the hydrogenated oils and trans fats.
  • Watch the glycemic load.
  • Eat cold water fish, nuts, seeds, game, grass fed beef and flax seed.
  • Garlic helds too.
Screen time: Just not good for you. ADHD is linked to early TV exposure. People still let their kids watch the tube. ADHD he can't treat with his supplements; you know what to do about this.
Sunshine: Vit D deficiency is a pandemic, he think. We are not out in the sun anymore. SAD is a real disease. He finds Vit D levels need to be augmented, and all mood disorders respond well to light therapy. Dawn simulator seems to work better.

So, you don't need to use drugs first. Honest.

In conclusion, Kathi took behavioral pediatrics and motivational interviewing into a comprehensive whole.
  • Pick a positive goal: Why is that important? Better mood, more cheerful.
  • Pick a specific strategy: What can you do about it? Exercise, sleep, nutrition or whatever.
  • Identify a small, achievable step: You've got to win early on. Be real specific. Important that they talk themselves into it, and that they have confidence that they can achieve it. Anticipate barriers, so that they don't talk themselves out of it.
  • Plan the reward/ celebration: How often and the timing?
From the the DBP Book, Miller and Roznick and Schwartz. You can really do this.
The questions are always the most interesting part of the session:
Jack Pascoe: How much does omega-3 fatty acids cost? There is a prescription form available in Colorado.
Person from AZ: Neonatologist worried about infant mental health. Maternal depression is a key problem; system is not in place to handle it.
Person from Columbia: Trying to do co-location, any thoughts. What is the business model that can sustain it. North Carolina is the model.

My fingers are beginning to tingle. I have to stop. Hope I captured this.

Rosie D. needs Resources: A bright spot in South Worcester County

So, as Rosie D. implementation moves forward, we are going to need additional resources to make this happen.  This was some good news from Harrington Hospital in Southbridge MA....

Southbridge, Mass.— On Thursday, May 8, 2008, at 5:30 PM, State Senator Richard Moore and State Representative Geraldo Alicea will join local families and mental health professionals to celebrate National Children’s Mental Health Day at Harrington Memorial Hospital’s George B. Wells Human Services Center. The ceremony, held at 54 Oakes Avenue in Southbridge, will showcase the community’s progress with children’s mental health initiatives and will include a ribbon cutting to open Harrington’s office for its Intensive Family Services Program, which recently relocated.
The third annual National Children’s Mental Health Awareness Day aims to raise awareness of effective programs for children’s mental health issues; demonstrate how these initiatives promote positive youth development, recovery, and resilience; and to show how children can thrive in the community.
“National Children’s Mental Health Awareness Day provides an important opportunity for our community to show how children and youth with mental health needs, as well as their families, thrive when they have the right supports and services available,” said Mirza Lugardo, Director of Harrington’s Intensive Family Services Program.
The Intensive Family Services Program at Harrington works with children and adolescents who have been clinically diagnosed and are being treated for mental disorders. This program is contracted by the Massachusetts Department of Mental Health. For more information about the Intensive Family Services Program, call 508-765-9167, ext. 4207.

We should all consider joining their celebration!

Saturday, May 3, 2008

Successful forum in Worcester

I am away for a few days, enjoying the pleasant sights and smells of hotel conference rooms, but I am still watching Central Mass achusetts through the eyes of the internet. In so doing, I got this email regarding Friday's forum on the Children's Mental Health Bill.
Hi David,
Great turnout (n=65ish), very informative and engaging speakers, lively discussion, Sen. Harriette Chandler spoke, Lisa Welsh from T&G in attendance. Lisa indicated that she is preparing a news article for tomorrow and Sunday as well.

Lynn Hennigan, MSW, M.Ed., LICSW
Director of Services for Young Children
Together For Kids Project Director
Community Healthlink

Sent: Friday, May 02, 2008 1:29 PM
To: Hennigan

Subject: Worcester Children's Mental Health Forum
How did it go? Anything I can say on the blog?
Click here for the article from the Telegram and Gazette on Friday. We will keep watching for the Sunday article. Nice quotes from Meri Viano in the article. Great work everyone.
ADDENDUM:  The Sunday article is here.  Again, nice work.

Friday, May 2, 2008

This just in from the Children's Mental Health Campaign

I just received this on an e-mail from Health Care for all. Stay tuned for more.

May 6 CMHC Bill Event Postponed

Due to logistical difficulties and unanticipated scheduling conflicts, the May 6 State House event has been postponed. We will be in touch at a later date with a new date and time.
It is still important that we continue our outreach to the Senate.

Please call your senator and ask he/she urge Senate President Murray and Ways and Means Chairman Panagiotakos to move SB 2518, An Act Relative to Children's Mental Health, out of the Ways and Means Committee and onto the Senate floor.

Click here to find out who your Senator is.
Click here for fact sheets and information.

Thursday, May 1, 2008

An Editorial Note

Please note that, while Robyn Miller (Advocate) has been granted privileges to post on this blog (as she represents the views of a substantial numbers of mental health workers in the Commonwealth), I don't always agree with her point of view. I am particularly troubled by her last post, and encourage comments (signed and anonymous) regarding suggestions of "prescreening" those parents deemed at high risk. Anytime someone starts talking about "those"people (nudge nudge, wink wink, say no more), we are on the the slippery slope to a racial and ethnic profiling. Even with universal screening, we must be very care not to stereotype and to never give up on the individual and family we have before us.

Also, while I have your attention, I hope that many of you are able to participate in Friday's event:

Worcester Children's Mental Health Forum.
Presented by Community Healthlink.
May 2, 2008, 8:30A-10A.
Community Healthlink Youth and Family Services,
275 Belmont St. Worcester MA.
Contact Joan Stewart (508)421-4519.

I am out of town, but would love to post something about it: e-mail a summary and I'll put it up here.

Guest Spot: Questions to the Commissioners

Here are two questions I have for the commissioners:

1) What can be done to decrease no-shows for children on Mass Health receiving mental health services? After speaking with providers across the domains, this population has the highest no-show rate for services. As a result, mental health clinics have challenges retaining mental health clinicians to work there. Will the commissions support paying for their no-shows?

2) What can be done to change the mindset that biology is destiny? Massachusetts is behind the times that any biological parent can parent their child without consequences. There are issues of high risk families leaving the hospitals with their infants when there are known facts that the parents may have mental health(untreated) or substance abuse problems. How come nothing is done to be prevent future damage these kids? I support prescreening these parents before they leavthe hospitals like they do for adoptive parents. Parenting comes from the heart and not
from chromosomes.

Robbin Miller
Advocate/Private Practitioner

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