Message from the Front Line: It Still Ain't Easy

So, I've have a couple more days on the front line, doing primary care.  Summertime in a pediatric practice  is mostly physicals and lyme disease, with a bit of coxsackie virus thrown in for good measure.  In our practice, however, the annual check-ups seem to involve a lot of kids who could well be friends of "Rosie D", families that would really benefit from the CBHI.   I have been singing the praises of the CBHI to many of those families, but I can already see soem of the roadblocks to enrollment in the new system.

1)  Fear:  Families of kids with serious emotional disturbance (SED) are used to being judged by others, but they still don't like it.  Is that child out of control because of biology or poor parenting?  Almost everyone has an opinion about what a family should do with a child who is behaving badly, and most of those opinions are formed without a full understanding of what is going on within the family.  A long history of being judged, however, makes it likely that you are not going to want to be judged in the future.  What happens if you go into this long and detailed assessment and you find out that it really is all your fault after all?

2)  Impatience:  Families of kids with SED often have a pretty sophisticated understanding of what makes their kid tick, and what would help them with behavioral management.  Now we want them to go through a 2 hour intake process, and a 4 hour CANS on the chance that they might get to sit in a 2 hour meeting to develop a plan over a 2 month period?  This does not sound terribly appealing, especially if the SED behaviors are slowly wearing down your spirit.    Saul Alinsky said that the key to successful community organizing (and this is community organizing, of a sort) is to have an early success, to give people hope.  Where is that "early success" in this approach?

3)  Hopelessness:  Some families of kids with SED have just given up;  they feel that they have exhausted the possibility of behavioral intervention, they have had therapists who didn't understand, they have seen psychiatrists on the 15 minute med check treadmill, and they don't see the possibility of something better than that.  It is hard work to build confidence in thos e families.

The key for us as primary care doctors is to walk with these families through the Valley, to see them past the fear and hopelessness and impatience, to convince that there is hope fo something better.

I saw families with all of these problems last week;  I am trying to walk them over to the CBHI.  One family, it turns out, had private insurance, even though they would be income eligible for SSI;  we are working with our legal aid attorneys to get that fixed.  Another wants psychopharmacology services, but no counseling.  Come to find out that her oldest son (not our patient) is now inpatient at a Psych Hospital, and she just can't deal with another system right now.  Another family has been a bit neglectful of check-ups and is about to move to another part of the state, to escape a domestic violence situation.  I am trying to assure some continuity of services, but am really not sure that will work.  None of these case have yet hit the CBHI;  I hope that the system is ready for them when they are ready for it.