1 integrating mental health into your primary care practice margaret bavis, dnp, fnp-bc sue murray,...

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Integrating Mental Health Into Your Primary Care Practice

Margaret Bavis, DNP, FNP-BCMargaret Bavis, DNP, FNP-BC

Sue Murray, RN, MPHSue Murray, RN, MPH

In collaboration with Sharon Stephan, PhDIn collaboration with Sharon Stephan, PhDCenter for School Mental HealthCenter for School Mental Health

NASBHC Training of TrainersNASBHC Training of TrainersSeptember 20-23, 2008September 20-23, 2008

Bringing Health Care to Schools for Student Success

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Ice-BreakerIce-Breaker

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Workshop ObjectivesWorkshop Objectives

Participants will be able to:

• Name at least two strategies for improving primary care-mental health collaboration in school-based health centers.

• Identify at least one screening instrument to screen for anxiety, depression, disruptive behavior disorders, and strengths and difficulties.

• Identify possible mental health diagnoses based on a list of presenting symptoms.

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Workshop Objectives (continued)Workshop Objectives (continued)

Participants will be able to:• Identify at least two core skills for treating

anxiety and depression.• Identify at least two strategies to improve

mental health referrals and documentation.

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Workshop OutlineWorkshop Outline

Mental health and primary care integration and collaboration

Risk and protective factor assessmentMental health screening toolsDiagnostic reviewTreatment, referrals and follow-upResources

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DefinitionsDefinitions Primary Care and Mental Health Integration -

integrating mental health practice into primary care services

Collaborative Care – primary care and mental health providers working collaboratively to provide quality health and mental health care

Interdisciplinary Practice - mutual respect and coordination of care between SBHC staff and other health professionals practicing in schools, including nurses, nutritionists, as well as mental health and other counseling professionals, see position statement at: http://www.nasbhc.org/atf/cf/{CD9949F2-2761-42FB-BC7A-CEE165C701D9}/Advocacy%20interdisciplinary%20pos.%20statement.pdf

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Primary Care Providers – Primary Care Providers – Why should I be doing mental health?Why should I be doing mental health?

I don’t have time

I’m not trained

I don’t like doing mental health work

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• In studies of SBHC service utilization, mental health counseling is repeatedly identified as the leading reason for visits by students.

• Approximately 1/3 to 1/2 of all visits to SBHCs are related to mental health problems.

• Only 16% of all children receive any mental health services. Of those receiving care, 70-80% receive that care in a school setting.

• Schools are the “de facto” mental health system for children and adolescents.

SOURCE: (1) National Assembly on School-Based Health Care. Creating Access to Care for Children and Youth: School-Based Health Center Census 1998-1999. June 2000. (2) Jellinek M, Patel BP, Froehle MC, eds., Bright Futures in Practice: Mental Health—Volume II. Tool Kit. Arlington, VA: National Center for Education in Maternal and Child Health. (4) Center for Health and Health Care in Schools, Children’s Mental Health Needs, Disparities, and School-Based Services: A Fact Sheet.

Importance of Mental Health Services in Importance of Mental Health Services in School-Based Health CentersSchool-Based Health Centers

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SBHC Staffing ModelsSBHC Staffing Models(N=1235)(N=1235)

Unknown4%

Primary Care-Mental Health

34%

Primary Care Only31%

Primary Care Mental Health

Plus31%

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Mental Health Services in SBHCs With (n=655) Mental Health Services in SBHCs With (n=655) and Without (n=277) Mental Health Providersand Without (n=277) Mental Health Providers

0 10 20 30 40 50 60 70 80 90 100

*Crisis Intervention

*Grief and Loss Therapy

*Psycho-education

*Assessment

*Screening

*Mental Health Diagnosis

*Brief Therapy

*Long Term Therapy

*Medication Management/Administration

*Case Management

*Skill-Building

*Referrals

*Substance Use Counseling

*Tobacco Use Counseling

*Conflict Resolution/Mediation

*Other

With Mental Health Provider Without Mental Health Provider

* P<.01

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Strategies for Improving Strategies for Improving Collaborative Care in SBHCsCollaborative Care in SBHCs Collaborative screening and assessment Chart/documentation Information sharing between mental health and

primary care providers Interdisciplinary case conferences Multidisciplinary training Co-facilitation of student groups Joint presentation of in-services to school staff Efficient, reliable, informative referral process

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Mental Health Problem IdentificationMental Health Problem Identification

Comprehensive Risk and Protective Factor Assessment

Mental Health Screening

Mental Health Diagnosis

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Assessment and ScreeningAssessment and Screening

Shouldn’t only mental health providers assess and screen for mental health?

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Assessment of Risk and Assessment of Risk and Protective FactorsProtective Factors

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What assessment tools is your What assessment tools is your SBHC using???SBHC using???

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During an office visitDuring an office visit……

Comprehensive Risk Assessment

Asset Checklist

Stress/Risk Factor Assessment

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Risk AssessmentRisk Assessment

A comprehensive annual risk assessment and biennial physical exam are essential to detecting and addressing all important health concerns of the student.

-NASBHC CQI Tool

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Risk Assessment Risk Assessment

injury safety violence diet and exercise dental substance use and

passive exposure

abuse family relationships school friends mood and emotional

health sexuality

Must be developmentally appropriate and is expected to cover:

- NASBHC CQI Tool

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Risk Assessment ToolsRisk Assessment Tools Guidelines for Adolescent Preventive

Services (GAPS)http://www.ama-assn.org/

ama/pub/category/1980.html

Bright Futureshttp://www.brightfutures.org

American Academy of Pediatricshttp://www.aap.org/policy/periodicity.pdf

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Risk Assessment ToolsRisk Assessment Tools

Pediatric Symptom Checklisthttp://www.massgeneral.org/

psc

Child Health and Illness Profile (CHIP)

http://chip.jhu.edu

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HEADSS interviewHEADSS interview

HomeEducationActivityDietSafetySexuality

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The Asset ChecklistThe Asset Checklist

Self-report40 developmental assets Identifies qualities in youth that can

be enhanced to promote resiliency.http://www.search-institute.org/assets/asset

lists.html

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Stress-Risk Factor Stress-Risk Factor AssessmentAssessment

Ask– “What 3 things do you think are causing you the most

stress lately?”;

– “What 3 things do you think are causing your family the most stress lately?”

– “What 3 things do you think are most stressful about your school?”

– “What 3 things do you think are most stressful about your neighborhood?”

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Considerations In Assessment Considerations In Assessment SelectionSelection

Be sensitive to age, sex, language, and culture

Be relevant to their needs or risk factors Practicality of implementing in your

practice Instruments should be “user friendly” Capture the information you need Be measurable Fit with your style of practice There is no best way

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How do you conduct the risk How do you conduct the risk assessment? assessment?

Paper and pencil – done by student Computer based Provider interview of student at the time

of the examination Provider interview of student at a time

apart from the examination

What works in your setting?

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Documentation of Risk and Documentation of Risk and Protective FactorsProtective Factors

Documentation may take many forms…– Inclusion of strengths/assets/protective

factors in intake evaluation, progress notes, and/or treatment plan

– Checklist of risk and protective factors– Assessment instruments (e.g.,

comprehensive risk assessment, asset checklist, etc.)

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Getting the assessment done: Getting the assessment done: Distribution of workDistribution of work

Identifying components of the work Identifying team rolesShared ResponsibilityStaff Training

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Screening InstrumentsScreening Instruments

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Screening Instruments – Screening Instruments – public domain (aka FREE)public domain (aka FREE)

General Mental Health – Strengths and Difficulties– Strengths and Difficulties Questionnaire

Disruptive Behavior Disorders/ADHD– Parent/Teacher Disruptive Behavior Disorders Rating Scale– Vanderbilt Scales– Disruptive Behavior Disorders Structured Parent Interview

Depression:– Center for Epidemiological Studies Depression Scale for

Children (CES-DC) Anxiety:

– The Spence Children’s Anxiety Scale (SCAS)

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Strengths and Difficulties Strengths and Difficulties QuestionnaireQuestionnaire

25-item self-report screening of strengths and difficulties for 3-16 year olds

5 subscales:– Emotional symptoms– Conduct Problems– Hyperactivity/inattention– Peer relationship problems

Prosocial Behavior Used as initial screener and/or measure of

treatment progress FREE! – available at http://www.sdqinfo.com/

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Parent/Teacher Disruptive Parent/Teacher Disruptive Behavior Disorders Rating ScaleBehavior Disorders Rating Scale

Disruptive Behavior Disorders45 itemsFREE! – available at

http://128.205.76.10/DBD.pdfParent and Teacher reportSubscales for:

– ADHD, ODD, CD

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Vanderbilt ScalesVanderbilt Scales

Parent and teacher versionsAlso screens ODD, Conduct

Disorder, and Anxiety/DepressionEasy to scoreFREE! – available at

http://www.nichq.org/resources/toolkit/

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Disruptive Behavior Disorders Disruptive Behavior Disorders Structured Parent InterviewStructured Parent Interview

Based on DSM criteria FREE! – available at

http://128.205.76.10/DBDInterv.pdfSubscales for:

– ADHD, ODD, CD

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Center for Epidemiological Studies Center for Epidemiological Studies Depression Scale for Children Depression Scale for Children

(CES-DC)(CES-DC)20-item self-report depression inventory

Used as initial screener and/or measure of treatment progress

FREE! – available athttp://www.brightfutures.org/mentalhealth/

pdf/professionals/bridges/ces_dc.pdf

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Center for Epidemiological Studies Center for Epidemiological Studies Depression Scale for Children Depression Scale for Children

(CES-DC)(CES-DC)Possible scores ranging from 0-60

Scale from 0 (Not at all) – 3 (A lot)

Developers indicate a cutoff score of 15 as suggesting depressive symptoms in children and adolescents.

Scores over 15 may be indicative of significant levels of depression

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The Spence Children’s Anxiety Scale The Spence Children’s Anxiety Scale (SCAS)(SCAS)

38 anxiety items Overall measure of anxiety with 6 subscales

tapping specific aspects of anxiety– Panic attack/agoraphobia– Separation anxiety– Physical injury fears– Social phobia– Obsessive compulsive– Generalized anxiety/overanxious disorder

FREE! – available at http://www2.psy.uq.edu.au/~sues/scas/

Parent and Child versions available

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Screening DiscussionScreening Discussion

In your SBHC, what factors would you need to consider if you were to implement mental health screening?– Who would do the screening?– When?– Who would score?– Who can diagnose?

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DiagnosisDiagnosis

Who me?… Diagnose?

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DiagnosisDiagnosis

DSM IV-TR (Diagnostic and Statistical manual, fourth edition, text revised)– Contains mental health diagnoses, as well as all the

criteria needed to make the diagnosis

– Created by a panel of experts who reach a consensus on what makes a diagnosis - based on their experience and evidence based research

– Often see a certain number of symptoms needed to make a diagnosis, i.e. 5 of 9 for depression.

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Diagnosis cont.Diagnosis cont.

Need some sort of impairment in an arena of patient’s life in order to make diagnosis– So, need to see impairment in social

interactions, school functioning, interpersonal interactions, etc.

DSM is updated every so often to indicate any prevalent changes in the field of psychiatry in regards to different diagnoses

Good for “common language”

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Diagnosis – Primary CareDiagnosis – Primary Care

DSM-IV-PC (Diagnostic and Statistical manual, fourth edition, primary care)

Primary Care Adaptation– emphasizes only those psychiatric disorders

that regularly present in primary care settings

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Diagnosis – Primary Care cont.Diagnosis – Primary Care cont.

Simplified Diagnostic Technique

– Nine algorithms, headed by presenting symptoms, for the most common psychiatric concerns encountered in primary care

– concise description of disorders as they clinically appear in primary care settings

– provides differential diagnoses as they relate to general medical conditions, substance abuse and more severe psychiatric disorders

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Memorizing the DSM-IVMemorizing the DSM-IV

Daniel Carlat’s, “The Psychiatric Interview”

Memorize the 7 Major Diagnostic Categories

Organized by category for memorization (not organized this way in DSM-IV)

Focus on Positive Criteria

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AnxietyAnxiety

Panic Disorder– Agoraphobia

Obsessive Compulsive Disorder Specific PhobiasSeparation Anxiety DisorderPosttraumatic Stress DisorderGeneralized Anxiety DisorderAnxiety Disorder NOS

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What type of anxiety???What type of anxiety??? Marcus has come for a follow-up

appointment at the School-Based Health Center (SBHC). He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

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Panic Disorder - Diagnostic CriteriaPanic Disorder - Diagnostic CriteriaI. Recurrent unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or discomfort, in

which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being detached

from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Parenthesis (numbness or tingling sensations) (13) Chills or hot flushes

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Panic Disorder - Diagnostic Panic Disorder - Diagnostic CriteriaCriteria

II. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(1) Persistent concern about having additional attacks

(2) Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")

(3) A significant change in behavior related to the attacks

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What type of anxiety???What type of anxiety??? Philip’s mother came to school to talk to

her son’s teacher (Ms. Chalk) because of Philip’s recent absences from school. Upon talking with Philip’s mother, Ms. Chalk learned that Philip had a fear of animals, and was increasingly scared to go outside of his house because he did not want to come into contact with any animals. His mother reported that he even gets nervous when seeing animals on television, even though he knows they cannot hurt him.

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Specific PhobiasSpecific Phobias Marked and persistent fear of a

specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable

In children, anxiety may be expressed as crying, tantrums, freezing, or clinging.

Adults recognize that their fear is excessive. Children may not.

Causes significant interference in life, or significant distress.

Under 18 years of age – symptoms must be > 6 months

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Specific PhobiasSpecific Phobias

Animal phobias most common childhood phobia.

Also frequently afraid of the dark and imaginary creatures

In older children, fears are more focused on health, social and school problems

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What type of anxiety???What type of anxiety???

Sally is brought to the school principal by her parents, who are worried about her poor attendance in school. Sally has had some difficulty leaving her parents for the past several years, but her concerns have grown increasingly more intense. She reports having fears that if she goes to school, her parents will abandon her or something very bad might happen to them. She sometimes has dreams that they have died, and she wakes up in a panic. Sally has come to the office several times in the past few months complaining of headaches and stomachaches, requesting that she be sent home.

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Separation Anxiety Separation Anxiety DisorderDisorder

Developmentally inappropriate and excessive anxietyconcerning separation from home or from those to whomthe individual is attached, as evidenced by three (or more)of the following:(1) Recurrent excessive distress when separation from home or

major attachment figures occurs or is anticipated(2) Persistent and excessive worry about losing, or about possible

harm befalling, major attachment figures(3) Persistent and excessive worry that an untoward event will lead

to separation from a major attachment figure (e.g., getting lost or being kidnapped)

(4) Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

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Separation Anxiety Separation Anxiety DisorderDisorder

(5) Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

(6) Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

(7) Repeated nightmares involving the theme of separation

(8) Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

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Separation Anxiety DisorderSeparation Anxiety Disorder

Duration of at least 4 weeks

Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning

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What type of Anxiety???What type of Anxiety???

James walks into the school nurse’s office for an appointment. He reports having great difficulty concentrating in his classes because of his increased worrying. He cannot pinpoint his worries; Rather, he reports being nervous about many things in his life, including his relationships with peers, his grades, and even his performance in basketball. His worries are beginning to impact his sleep, and he is finding himself becoming more irritable than usual.

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Generalized Anxiety DisorderGeneralized Anxiety Disorder Excessive anxiety and worry for at least 6

months, more days than not Worry about performance at school, sports,

etc. DSM IV criteria less stringent for children

(Need only one criteria instead of three of six):

(1) Restlessness or feeling keyed up or on edge

(2) Being easily fatigued

(3) Difficulty concentrating or mind going blank

(4) Irritability

(5) Muscle tension

(6) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

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Generalized Anxiety Disorder:Generalized Anxiety Disorder:Macbeth Frets Constantly Regarding Macbeth Frets Constantly Regarding

Illicit SinsIllicit Sins3/6 for 6 months…3/6 for 6 months…

Muscle tensionFatigueConcentration problemsRestless, feeling on edgeIrritabilitySleep problems

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What type of anxiety???What type of anxiety???

Shelley’s teacher calls Shelley’s parents because he is concerned that her grades have been declining, and he has noticed that she has not been completing her homework. Shelley reports that she is being plagued by distressing thoughts of doing bad things, including hurting herself and others. In order to get rid of the thoughts, Shelley often has to engage in intricate routines, including counting to 100 and backwards, and touching her desk at home in specific patterns. Although these routines decrease her anxiety, they are causing her to skip homework assignments and even lose sleep.

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Obsessive Compulsive Obsessive Compulsive DisorderDisorder

Presence of Obsessions (thoughts) and/or Compulsions (behaviors)

Although adults may have insight, kids may not

Interferes with life or causes distress

One third to one half of all adult patients report onset in childhood or adolescence

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What type of anxiety???What type of anxiety??? Ginny comes to the SBHC for a sports

physical. During her risk assessment, she reveals that her parents have a history of domestic violence, and that she witnessed her father attack her mother on several occasions. In the past few months, Ginny has been having nightmares about the abuse, and finds herself having flashbacks even during class. Ginny has been avoiding certain rooms in her house that remind her of the incidents. She also reports having difficult sleeping and concentrating in class.

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Post-traumatic Stress Disorder (PTSD)Post-traumatic Stress Disorder (PTSD)The person has been exposed to a traumatic event in which

both of the following were present: (1) The person experienced, witnessed, or was

confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) The person's response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior.)

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Persistent Re-experiencing of event (1+)Persistent Re-experiencing of event (1+)

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.)

(2) Recurrent distressing dreams of the event. (Note: In children, there may be frightening dreams without recognizable content.)

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.)

(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

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Avoidance and Numbing (3+)Avoidance and Numbing (3+)(1) Efforts to avoid thoughts, feelings, or conversations associated with the

trauma

(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) Inability to recall an important aspect of the trauma

(4) Markedly diminished interest or participation in significant activities

(5) Feeling of detachment or estrangement from others

(6) Restricted range of affect (e.g., unable to have loving feelings)

(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

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Increased Arousal (2+)Increased Arousal (2+)

(1) Difficulty falling or staying asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hypervigilance

(5) Exaggerated startle response

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Posttraumatic Stress Disorder (PTSD)Posttraumatic Stress Disorder (PTSD)

At least one month duration.

Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Note: Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) – both should be diagnosed

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Posttraumatic Stress Disorder:Posttraumatic Stress Disorder:Remembers Atrocious Nuclear AttacksRemembers Atrocious Nuclear Attacks

Re-experiencing the trauma via intrusive memories, flashbacks or nightmares (one required)

Avoidance of stimuli associated with trauma and Numbing such as avoiding things associated with trauma, amnesia, restricted affect and activities, detachment, foreshortened future (one required)

Symptoms of increased Arousal such as insomnia, irritability, hypervigilance, startle response, poor concentration (two required)

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Anxiety Disorder NOSAnxiety Disorder NOS

Disorders with anxiety symptoms BUT do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood

Example: mixed anxiety-depressive disorder

Also used in situations in which clinician has concluded that an anxiety disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

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Depressive DisordersDepressive Disorders

Major Depressive Disorder

Dysthymic Disorder

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DepressionDepressionEpidemiology

2.5% of children, up to 5% of adolescents Prepubertal-1:1/M:F; adolescence-4:1/F:M Average length of untreated MDD-7.2 months Recurrence rates-40% within 2 years

Genetics

Most important risk factor for the development of depressive illness is having at least one affectively ill parent

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What type of depression??What type of depression?? Tonya comes to health class looking “down in

the dumps,” as she had for past few weeks. Tonya’s teacher asks to speak with her after class, and finds out that Tonya has a number of depressive symptoms, including suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that s/he will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade. Tonya has felt extremely sad for about three weeks, which is a contrast from her usually happy disposition.

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Major Depressive DisorderMajor Depressive Disorder Major Depressive Episode:

Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure.

– Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as irritability.

– Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

– Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day

– Insomnia or hypersomnia nearly every day– Psychomotor agitation or retardation nearly every day (observable by

others)– Fatigue or loss of energy nearly every day– Feelings of worthlessness or inappropriate guilt nearly every day– Diminished ability to think, concentrate, make a decision nearly every day– Recurrent thoughts of death, recurrent suicidal ideation with or without a

specific plan, or an actual suicide attempt

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Major Depressive DisorderMajor Depressive DisorderII. Symptoms cause clinically significant

distress or impairment in social or academic functioning

III. Symptoms are not due to the direct physiological effects of a substance (drugs or medication) or a general medical condition

Although there is a different diagnostic category for individuals who suffer from Bereavement, many of the symptoms are the same and counseling techniques may overlap.

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DepressionDepressionModifications in DSM- IV for children:

irritable mood (vs. depressive mood)

observed apathy and pervasive boredom (vs. anhedonia)

failure to make expected weight gains (rather than significant weight loss)

somatic complaints social withdrawal declining school

performance

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Depressed Patients Sound Depressed Patients Sound Anxious, So Claim Psychiatrists Anxious, So Claim Psychiatrists

Depression & Other Mood DisordersPsychotic DisordersSubstance Abuse DisordersAnxiety DisordersSomatoform DisordersCognitive DisordersPersonality Disorders

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Major Major DDepression: SIGECAPSepression: SIGECAPS4/8 with depressed mood or anhedonia for 2 weeks4/8 with depressed mood or anhedonia for 2 weeks

Sleep disturbance (increased or decreased)Interest deficit (anhedonia)Guilt (worthlessness, hopelessness, regret)Energy deficitConcentration deficitAppetite disturbance (increased or

decreased)Psychomotor retardation or agitationSuicidality

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Adolescent DevelopmentAdolescent Development

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Adolescent DevelopmentAdolescent Development

• Periods of transient milder problems with low self-esteem, anxiety, depressive feelings are quite common.

• Needs to be differentiated from clinical depression!

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SuicideSuicide Attempts- 3:1/F:M, Completions- 4:1/M:F

Most common means of completed suicide: FIREARMS

Most often associated with depressive disorder.

Risk factors: Age, sex, presence of psychiatric illness, family history, isolation from friends, substance abuse

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Risk Factors for Suicide: Risk Factors for Suicide: SAD PERSONSSAD PERSONS

• Sex: Attempts- 3:1/F:M, Completions- 4:1/M:F

• Age: teenagers and elderly at highest risk• Depression: 15% of people with

depression die by suicide• Previous Attempt: 10% of those who have

previously attempted die by suicide• Ethanol abuse: 15% of alcoholics commit

suicide

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Risk Factors for Suicide: Risk Factors for Suicide: SAD PERSONS cont.SAD PERSONS cont.

• Rational thinking loss: Psychosis is a risk factor, 10% of those with chronic schizophrenics die by suicide

• Social supports are lacking• Organized plan: a well formulated plan is

a red flag• No spouse: being divorced, separated or

widowed. Having responsibility for children is an important statistical protector

• Sickness: chronic illness

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What type of depression??What type of depression?? Maria comes for a follow-up appointment to

the SBHC. Her risk assessment showed that she has felt sad or blue for at least two weeks. Upon further inquiry, Maria reports that she generally feels sad, and finds little enjoyment in activities. She reports having felt this way for several years. In fact, she can’t recall a time when she didn’t feel mostly down. She denies suicidal ideation, and is doing pretty well in school. She is not very social, but does have a few friends.

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Dysthymic DisorderDysthymic Disorder Major difference between a diagnosis of Major

Depressive Disorder and Dysthymia is the intensity of the feelings of depression and the duration of symptoms.

Dysthymia is an overarching feeling of depression most of the day, more days than not, that does not meet criteria for a Major Depressive Episode.

Impairs functioning and lasts for at least one year in children and adolescents, two in adults.

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Dsythmia: ACHEWSDsythmia: ACHEWS2/6 with depressed mood for 2 years2/6 with depressed mood for 2 years

Appetite disturbance Concentration deficitHopelessnessEnergy deficitWorthlessnessSleep disturbance

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Depressive Disorder NOSDepressive Disorder NOS Disorders with depressive symptoms BUT do not

meet criteria for: Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood

Examples: premenstrual dysphoric disorder, minor depressive disorder (at least 2 weeks, but < 5 symptoms)

Also used in situations in which clinician has concluded that a depressive disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

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Disruptive Disorders in ChildrenDisruptive Disorders in Children

Attention Deficit Hyperactivity Disorder

Oppositional Defiant Disorder

Conduct Disorder Disruptive Behavior

Disorder NOS

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What type of Disruptive Behavior What type of Disruptive Behavior Disorder?Disorder?

Joseph was referred to the main office by his teacher for disrupting her class. Joseph’s teacher reported that she cannot manage him in class because he is constantly out of his seat and will not concentrate on work. He has a hard time completing tasks, and is very disorganized. He talks back to her occasionally when frustrated, but is not frequently defiant. His peers are getting tired of him constantly interrupting them, and he is losing friends quickly.

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Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

Symptoms for at least six months to a degree that it is maladaptive and INCONSISTENT with developmental level

Some symptoms present prior to age 7 years

Two or more settings

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Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

Inattention Poor organization Does not seem to

listen when spoken to

Loses objects Easily distracted Forgetful in daily

activities

Hyperactivity/Impulsivity Fidget Leaves seat often Runs or climbs

excessively Always “on the go” Talks excessively Blurts out answers Can’t wait turn,

interrupts others

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Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

Attention deficit disorder can occur WITH and WITHOUT hyperactivity

Hyperactivity is more common in boys than girls

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Attention Deficit Hyperactivity Attention Deficit Hyperactivity DisorderDisorder

ADHD can be a lifetime disorder with 30-50% having symptoms as adults

Learning Disabilities are frequently seen in children with ADHD

Behavior in a provider’s office does NOT always reflect the situation at home or in school

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What type of Disruptive Behavior What type of Disruptive Behavior Disorder?Disorder?

The principal of your school has called you to a meeting with Jonathon’s parents and his teachers, all of whom complain that Jonathon has been “acting out” for over a year, and refuses to listen to their direction. He is constantly arguing with all authority figures, and will not take responsibility for his actions. Jonathon’s teacher and mother say that he is “always angry,” and that he lashes out at everyone around him. He has been breaking more rules at home and in school. He has not been drinking alcohol or using drugs, nor has he broken the law up until this point, but his parents are worried that his behaviors are going to grow steadily worse.

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Oppositional Defiant DisorderOppositional Defiant Disorder

A pattern of negativistic, hostile and defiant behavior lasting greater than 6 months of which you have 4 or more of the following:

Loses temper Argues with adults Actively defies or refuses to comply with rules Often deliberately annoys people Blames others for his/her mistakes Often touchy or easily annoyed with others Often angry and resentful Often spiteful or vindictive

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Oppositional Defiant DisorderOppositional Defiant Disorder(ODD)(ODD)

Prevalence-3-10% Male to female -2-3:1 Outcome-in one

study, 44% of 7-12 year old boys with ODD developed into CD

Evaluation-Look for co morbid ADHD, depression, anxiety &LD/MR

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What type of Disruptive Behavior What type of Disruptive Behavior Disorder?Disorder?

Matthew was referred to the school social worker because he has been “going down the wrong path for several years,” according to his mother. Matthew’s negative behaviors began before puberty, when he started hanging out with negative peers. Matthew’s mother has caught him hurting their family pet as well as other animals, and he was recently arrested for vandalizing school property. He has been getting into frequent fights at school without apparent instigation. Matthew’s mother also realized that he had stolen from her when she noticed $50 missing from her purse and found it in his pocket.

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Conduct DisorderConduct Disorder(CD)(CD)

Aggression toward people or animals

Deceitfulness or Theft

Destruction of property

Serious violation of rules

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Conduct DisorderConduct Disorder(CD)(CD)

Prevalence-1.5-3.4% Boys greatly

outnumber girls (3-5:1)

Co morbid ADHD in 50%, common to have LD

Course-remits by adulthood in 2/3. Others become Antisocial Personality Disorder

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Conduct DisorderConduct Disorder

“You left your D__M car in the driveway again!”

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Disruptive Behavior Disorder NOSDisruptive Behavior Disorder NOS

Disorders characterized by conduct or oppositional defiant behaviors that do not meet criteria for ODD or CD

Still must have impairment in functioning

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Substance Abuse/DependenceSubstance Abuse/Dependence* acknowledgement to Judith Rubenstein, Boston University, for * acknowledgement to Judith Rubenstein, Boston University, for Substance Abuse slidesSubstance Abuse slides

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EpidemiologyEpidemiology

Alcohol & drug abuse is of epidemic proportion in adolescents and is a major public health problem

Highest prevalence of abuse in 18 to 22 y.o. Greatest risk for abuse when onset before 15yo

&/or mental disorder present Use of gateway drugs (alcohol, tobacco,

cannabis, inhalants) starting at younger ages ~50% of adolescents experiment with illicit

substances at some point

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Underage drinking….Underage drinking….

16% of all alcohol sales (2001)

3,170 deaths & 2.6 million harmful events

$62 billion in direct and indirect costs

Miller TR, Levy DT, Spicer RS, Taylor DM.Miller TR, Levy DT, Spicer RS, Taylor DM.Societal costs of underage drinking. Societal costs of underage drinking. J Studies on Alcohol 2006; 67: 519-528.J Studies on Alcohol 2006; 67: 519-528.

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binge drink drive after drinking ride with a drinking driver be injured in fights or carry a weapon use other illicit drugs perform poorly in school become alcohol dependent as a young adult

Adolescents who begin drinking before age 15 are more likely to:

We have recently learned that early intervention We have recently learned that early intervention is more important than we thought….is more important than we thought….

Data from a series of papers published fromData from a series of papers published fromThe Boston University Youth Alcohol Prevention CenterThe Boston University Youth Alcohol Prevention Center

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Adolescent Brain ChangesAdolescent Brain Changes Earlier drinking more likely to result in

alcohol dependence independent of family hx (Grant 1998)

Exposure of alcohol may indeed cause alterations in brain chemistry…. There are studies indicating heaving drinking during adolescence causes memory and neuropsychological changes (Brown, et al)

Animal studies show that early exposure to alcohol results in longer term problems such as cognitive and behavioral problems

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Adolescent Drug UseAdolescent Drug Use Experimentation with substances is common,

particularly during adolescence. Teenagers use alcohol and drugs for a variety of

reasons:– curiosity– to reduce stress– to fit in with a peer group– it feels good

Difficult to determine which youths will experiment and stop and which will develop more serious problems with substances.

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Now What?:Now What?:

• Family engagement

• Treatment planning

• Interventions/core skills

• Referrals

• Follow-up

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Engaging Family in ServicesEngaging Family in Services

Family engagement is crucial even for adolescents Interventions must take into account child’s

developmental needs Educate family about benefits of their participation

– improve emotional climate of family– increase cohesion– reduce conflict

Help family with other things they need – be helpful person in multiple ways

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Family InterventionsFamily Interventions

Make services user-friendly to parents Validate parent frustration and the fact that child is difficult Never blame parents for child’s problems Appeal to parent’s desire for things to be better Address misperceptions about learning parenting skills Utilize Behavior Management and Parent Training

Techniques Involve youth in family decision making and rule-setting –

parents need to learn how to go “one down” to go “one up”

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Mental Health Treatment PlanningMental Health Treatment Planning

What do you include in your treatment plan?– Identify Strengths– Identify Needs/Problems– Match interventions to needs/problems– Identify who will implement intervention– Identify short- and long-term goals with timeline

and make these clear to student/family

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Training in Training in Core Core

Cognitive Cognitive Behavioral Behavioral

SkillsSkills

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What are “core skills”?What are “core skills”?

Based in cognitive behavioral theory

Buffer against the development of mental health problems

Assist in coping with mental health problems

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What is Cognitive Behavior Therapy What is Cognitive Behavior Therapy (CBT)?(CBT)?

Relatively short-term, focused psychotherapyFocus:

– How you are thinking (your cognitions)– How you are behaving and communicating

Emphasis on present rather than pastLearn coping skills

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Skills training for AnxietySkills training for Anxiety

Deep Breathing Progressive Muscle

Relaxation Mental

Imagery/Visualization General Stress Busters Cognitive Restructuring Systematic

Desensitization

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Skills training for DepressionSkills training for Depression

Thought Stopping Activity Scheduling Problem Solving Relaxation Training Cognitive

Restructuring

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Substance Abuse Strategies and SkillsSubstance Abuse Strategies and Skills

• Individual, family and classroom- based interventions• Substance Abuse screening • Motivational Interviewing • Refusal Skills• Self-Esteem• Education• Referrals

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““Core Skills” ResourceCore Skills” Resource

Stephan, S. H., & Marciante, W. (2007). Quick Guide to Clinical Techniques for Common Child and Adolescent Mental Health Problems. Baltimore: University of Maryland Center for School Mental Healthhttp://www.schoolmentalhealth.org/Resources/Clin/QuickGuide.pdf

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Medication ManagementMedication Management

• Factors to consider:– Diagnosis and symptoms– Resources for referral– Provider competence– Provider availability for monitoring– Family support– School support for the administration of

psychotropic medication in the school

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Medication ManagementMedication Management

• Develop protocol for SBHC that includes– Referral for therapy− Full assessment− Consultation− Documentation− Education of student and family− Follow up, follow up, follow up!

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Medication ResourcesMedication Resources

Psychotropic Drugs and Children A 2007 UpdateDecember 2007The Center for Health and Health Care in Schools

http://www.healthinschools.org/News%20Room/Fact%20Sheets/Psychotropic.aspx

Facts for FamiliesAmerican Academy of Adolescent and Child Psychiatryhttp://www.aacap.org/cs/root/facts_for_families/psychiatric_medication_for_children_and_adolescents_part_ihow_medications_are_used

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Strategies to Facilitate Strategies to Facilitate ReferralsReferrals

Internal referrals:– Referral log

– Referral form with feedback form

– Interdisciplinary case conferences

– Follow-up documentation in charts

External referrals:– Community resource directory

– Established relationships with community mental health providers/sponsoring organization

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Referral FormReferral Form

Students name, grade, homeroom Date of referral Name of person referring Reason for referral Urgency of referral Have you talked to student or family about this

referral? Date referral was received and reviewed

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Referral FeedbackReferral Feedback Get consent from student to provide feedback to

referral source Feedback can be verbal or written Feedback form can include:

– student has not responded to appointment requests– student or parent declined counseling services– status of evaluation, type of service student is receiving– student was referred for outside evaluation/treatment– student’s difficulties appear to be resolved– student is receiving mental health services from another

provider

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Interdisciplinary Case ConferencesInterdisciplinary Case ConferencesUsed for:

– case management– referrals– problem-solving over difficult cases– information sharing– multi-disciplinary training– team-building

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How To Set Up Case ConferencesHow To Set Up Case Conferences

Who will coordinateWhich staff should participateTime and frequencyPrioritization of casesDocumentationFollow-up from previous conferencesIdentify additional training needs

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Mental Health Progress Notes-- Mental Health Progress Notes-- What to include?What to include?Date, Time, DurationDiagnosisType of ContactContent of SessionAssessment StrategiesIntervention Strategies (e.g. CBT)Progress on Objective Treatment GoalsFamily InvolvementPlans for Future Intervention

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Benefits of Good Mental Health Benefits of Good Mental Health DocumentationDocumentation

Assists in monitoring of treatment progressMindful of different components of

treatment – family involvement, assessment, intervention (not just content)

Structures intervention around treatment goals/objectives

Liability!

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ResourcesResources

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NASBHC Resources NASBHC Resources www.nasbhc.orgwww.nasbhc.org

Mental Health Section:– Screening and assessment tools– Mental Health Planning and Evaluation

Template– Links to other school mental health resources

Technical Assistance Section:– Training opportunities– Professional Development– Annual Convention!!

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Welcome to the School Mental Health Connection!

This site offers school mental health resources not only for clinicians, but also for educators, administrators, parents/caregivers, families, and students. To efficiently find resources that fit your needs, just click the link to the left that corresponds to your role in the school community.  However, since you may benefit from resources in numerous domains within this site, we encourage you to explore many areas.The resources on this site emphasize practical information and skills based on current research, including prominent evidence-based practices, as well as lessons learned from local, state, and national initiatives. 

The School Mental Health Connection is designed for use by anyone who is interested in school mental health.  It is also a central feature of the Baltimore School Mental Health Technical Assistance and Training Initiative.

What's NewView the newly-released Directory of Community Services for Baltimore City.Educators:  Check out the user-friendly Mental Health Fact Sheets for the Classroom, provided by the Minnesota Association for Children's Mental Health.

Home

About Us

Resources for Clinicians

Resources for Educators

Resources for Families

Resources for Students

FAQ

Baltimore City Resource Directory

Consultation &

Support Line © 2006 The School Mental Health Connection. All Rights Reserved.

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Other Helpful Other Helpful School Mental Health WebsitesSchool Mental Health Websites

Center for School Mental Healthhttp://csmha.umaryland.edu

Center for Health and Healthcare in Schoolshttp://www.healthinschools.org

UCLA Center for Mental Health in Schools http://smhp.psych.ucla.edu

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Other Helpful ResourcesOther Helpful Resources

Adolescent Health Working Group adolescent provider toolkithttp://www.ahwg.net/resources/toolkit.htm

Integrated Primary CareAlexander Blount, Ed.D.http://www.integratedprimarycare.com/

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Questions?

Evaluations, please.

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Contact InformationContact Information

Sue Murray, MPH, RNProgram Consultant

Illinois Coalition for School Health Centers

smurray@ilmaternal.org

Margaret Bavis, DNP, FNP-BCInstructor

Rush University College of Nursingmargaret_bavis@rush.edu