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Welcome to Children’s TIPS 7th AnnualAbigail Schlesinger MD
Agenda (AM)
8:00 to 8:15 a.m. Sign into Meeting
8:15 to 8:30 a.m. Introduction to TiPS
Abigail Schlesinger, MD
8:30 to 9:30 a.m. Brief Behavioral Health Interventions for Primary Care Providers
Abigail Schlesinger, MD, and Colleen Gianneski, LCSW
9:30 to 9:40 a.m. Break
9:40 to 10:40 a.m. Internalizing Disorders I
Abigail Schlesinger, MD, and Kelley Victor, MD
10:40 to 10:50 a.m. Break
10:50 to 11:50 a.m. Internalizing Disorders II
Abigail Schlesinger, MD, and Kelley Victor, MD
11:50 – 1:00 p.m. Lunch
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Agenda (PM)
1:00 – 2:00 p.m. ADHD Medications
Rebecca Miller, MD
2:00 – 2:10 p. m. Break
2:10 – 3:10 p.m. Internalizing Disorders III
Abigail Schlesinger, MD, and Kelley Victor, MD
3:10 – 3:20 p.m. Break
3:20 – 4:20p.m. COVID
Justin Schreiber, DO
4:20 – 4:30 p.m. Closing Remarks
Abigail Schlesinger, MD
Learning Objectives
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Goals of Children’s TiPS• TiPS is a FREE service to help primary care clinicians(PCCs)
deliver high quality psychotropic services for children and adolescents served by Medicaid, CHIP and UPMC by providing:– Psychiatric curbside consultation Monday - Friday 9-5pm– Additional training on the use of psychotropic medication and
responding to behavioral health issues in a primary care setting– Direct consultation with patients when needed in Pittsburgh, Erie,
or telehealth with a licensed therapist and/or child psychiatrist– Facilitated referrals to community providers when
child/adolescent would benefit from additional behavioral health services
Process
PCC and TiPS child psychiatrist consult via phone
TiPS care coordinator provides resources to PCC or family, if needed virtual Evaluation with TiPS licensed therapist or child psychiatrist, if needed
Call: 1-844-WPA-TIPS(1-844-972-8477)
Talk to TiPS team member, who will gather basic information and initiate a return call from a TiPS child psychiatrist (within 30 minutes or at a time specified by PCP)
PCC has a question about psychotropic medication or a behavioral health concern
PCC obtains verbal consent & has patient information available
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SMART Choices Support for
SBIRT Implementation
• Primary Care
• Behavioral Health
• Substance Use Providers
• Schools
• Community Members
Learning Collaboratives
• Primary Care
• Behavioral Health
• Substance Use Providers
• Community Members
Train the Trainers
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Brief Behavioral Interventions for Primary Care
TiPS Conference, April 9, 2021
Abigail Schlesinger MD
Colleen Gianneski LCSW
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Your THERAPEUTIC SKILLS can improve the trip.
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Therapeutic Toolbox
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Follow-up
Non-medication Interventions
Safety Planning
Medication
Referral and Coordination
Nonmedication Skills & Intervention
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Relationship
HELLPP Skills
Assessment
Health Behavior Interventions
BH Interventions
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HELLPPP Skills
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H = Hope
E = Empathy
L 2 = Language, Loyalty
P 3 = Permission, Partnership, Plan
American Academy of Pediatrics. Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. Elk Grove Village, IL: American
Academy of Pediatrics; 2010. Updated May 2017.tClick to add text
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Common Factors Interventions: HELPCommon • Hope: Increase the family’s hopefulness by describing your realistic expectations for
improvement and reinforcing the strengths and assets you see in the child and family
• Empathy: Communicate empathy by listening attentively, asking clarifying questions.
• Language and Loyalty: Reflect what you hear; allow the patient family the opportunity to correct any misperceptions; communicate your support and commitment to help
• Permission, Partnership & Plan: Ask for permission to ask additional questions or make suggestions; partner with child and family by working together to overcome barriers and identifying achievable steps that align with the family’s motivation; Establish a plan (or incremental first steps)
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Organizing the Session
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• I understand you are here for help with your mood. Today I am going to ask questions and listen to you so that I can better understand your concerns. Then we will come up with initial goals/strategies to improve your mood.
Set Agenda
Recognize frustration/fears/anger/strengths AND instill hope
• Listen and Ask targeted questions sleep, appetite, routines, school, friends, mood, hope/helplessness
Clarify Needs(assessment, differential, safety planning)
Create clear plans
Recognize frustration/fears/anger/strengths & Instill Hope
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Empathic Statements
“This has been really difficult”
“you haven’t gotten much help with this yet”
“must be really frustrating”
Emphasize hope & foster emotional regulation
“you’ve handled difficulty things before. Remember when,,,”
“I recognize this problem and have some ideas about how to
handle it”
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Brief Behavioral Interventions by Chief Complaint
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Sluggish, Irritable, Amotivated
Avoidant, fearful, anxious
Busy Body, busy brain
Chief Complaint:
• Sluggish
• Irritable
• Amotivation
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Skill: Activation
But what exactly is behavioral activation?
Behavioral activation is based on the theory that as individuals become depressed -they tend to avoid and isolate - avoidance and isolation maintains or worsen their symptoms
Behavioral activation is a skill that can help children and teens get unstuck from negative mood spirals
Behavioral activation helps children and teens engage in mood and confidence boosting activities
Skill: Activation
How to explain activation to a child or adolescent?
• The activities we engage in make a difference and can help us feel better or can lead to feeling worse
• Focusing on activity is a great place to start! (vs thoughts or feelings/ with or without medication)
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Skill: ActivationIn contrast to coping skills for anxiety that sometimes can offer quick relief, it’s a little tricker to find skills that provide “quick wins” for kids with low/irritable mood.
Where to start?
• Start with talking about activities that they enjoyed before feeling down
• Think about other daily activities/routines that are not-so-routine anymore
• Examine sleep routines and eating habits, but don’t be generic about it (“Exercise more and eat better” will likely be ignored)
Skill: Activation
What next?
• Set realistic expectations (Think recovery from an injury – slow and steady – needs help/assistance - celebrate small success – help them identify 1st step)
• Be specific and involve the child/teen (Think SMART Goals)
• Take a team approach (Involve others – not just the responsibility of the child/teen)
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Skill: Activation
Kids
• “Pick up sticks” AM/ PM
Teens
• Fab Four
Pick Up Sticks
Supplies Needed:
• Popsicles sticks (small pieces of paper or index cards)
• 2 cups (one for AM and one for PM)
Instructions: Have child and parents make 2 lists
1. Activities that child can do by themselves
2. Activities that family can do together
Goal: Pick one activity from each cup daily
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Fab Four
Enjoy “I did it!” Active Social
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Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Brief Behavioral Interventions by Chief Complaint
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Sluggish, Irritable, Amotivated
Avoidant, fearful, anxious
Busy Body, busy brain
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Chief Complaint:
• Avoidant
• Fearful
• Anxious
Skill: Exposure
But what exactly is exposure?
Exposure is an intervention that was developed to help people confront their fears. When people are fearful of something, they tend to avoid the feared objects, activities or situations.
Although this avoidance might help reduce feelings of fear in the short term, over the long term it can make the fear become even worse. Exposure can help break the pattern of avoidance and fear.
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Skill: Exposure Exposure = Desensitize
Example: Allergy Shots
• Desensitize body’s physical reactions to
an environmental trigger by injecting a known allergen
into the body, which over time will reduce
the body’s physical reaction to that allergen
• We can explain anxiety the same way - it’s brain/body
overacting to a trigger that is perceived as dangerous. Exposures
are the “shot” that re-wires the brain and reduces the reaction over time
Skill: Exposure
Other ways to exposure to children and teens?
• Cold Swimming Pool
• Movie Theater
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Skill: Exposure
How to explain exposure to parents?
Anxiety is:
• Overestimation of risk
• Underestimation of confidence
Part of the brain where anxiety lives…
• Does not understand language (why reassurance hasn’t helped)
• Does understand behaviors (why avoidance/rescuing doesn’t help)
Exposures allow their child…
• Challenge risk in calculated way (prove the brain wrong)
• Improve confidence (they did it!)
Benefits to “riding it out”
Our brain remembers successWe learn “what goes up, will come down” by actual experience We find increased confidence with each step (I can do it!)We receive positive reinforcement
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Step 3
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Problems with Rescuing
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• Brain remembers the situation at its most uncomfortable point
• Take away the opportunity to learn “ride it out”
• No feeling of mastery (I can’t do it!)
• Reinforces avoidance
• Increased fear
Skill: Exposure
Kids & Teens
• Fear Ladder
• 1-2-3 Worry
• Scheduled Worry Time
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Fear Ladder Tips
• Child/teen picks the challenge!
• It’s helpful to use a fear thermometer or a Likert scale when brainstorming potential steps
• Sometimes it’s easier for the child/teen to identify the hardest step first (bullseye); Then ask… “What do you think would be a little easier than that?” (repeat)
• The child/teen stays on the step until anxiety goes down (preferably 50%)
• The child/teen discuss ahead of time what the role of the parent is (are they involved or not?)
• If you hit a roadblock – step back – don’t leave – may need to identify a “half-step” (somewhere between the last step and the next step on the ladder)
Finding the behavioral “sweet spot”
Good
Performance
Poor
Pressure, Fear, Stress
Low (Don’t care) Medium High (Freak out)
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Fear Ladder
I did it!
Step 5: Practice 1:
Step 4: Practice 1: Practice 2:
Step 3: Practice 1: Practice 2: Practice 3:
Step 2: Practice 1: Practice 2: Practice 3: Practice 4
Step 1: Practice 1: Practice 2: Practice 3: Practice 4: Practice 5:
1-2-3 Worry
This is a skill that you can teach a parent that is providing too much reassurance around repetitive worry questions.
1. Answer the question
2. Ask the child to recall the answer independently
3. Label the worry & ask the child what they/we can do to boss-back the worry
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Scheduled Worry Time
This is a skills that will help child/teen/parent set boundaries around worries.
• Pick a time to worry (can be brief)
• Decide who, what, where & when
• When a worry thought or worry talk “pops up”… practice saving it until worry time (exposure)
• Worry on purpose during that time – puts you in charge/ not your worries (exposure)
o Think / Write & Read / Record & Listen / Show (“OK”)
Brief Behavioral Interventions by Chief Complaint
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Sluggish, Irritable, Amotivated
Avoidant, fearful, anxious
Busy body, busy brain
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Chief complaint:
• Busy Body
• Busy Brain
Skill: Relaxation What is relaxation?• The state of being free from tension and anxiety
• Recreation or rest, especially after a period of work (before?)
• The loss of tension in a part of the body
• Physics: the restoration of equilibrium following a disturbance (before?)
How do I explain it to a child or teen? • Power down
• Reset
• In control
When do I do it? • Importance of practicing (think about any new skills – practice before we perform / advise against only using in-
the-moment because new things are HARD and this will likely lead to even more frustration!)
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Deep Breathing
Kids & Teens
• 4-4-8 (or 3-3-6)
• Bubble Breathing
Deep Breathing
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Progressive Muscle Relaxation
Kids
• Calm down turtle
Teens
• Making lemonade
Calm Down Turtle
• Talk about how turtles sometimes put their head,
arms and legs inside their shell
• Practice together
• Reward home practice1) Child colors 1 section of turtle every time they practice
at home
2) Child colors 4 sections of turtle every time they use the
technique to calm down
3) 4 sections = small reward / whole turtle = big reward
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Brief Behavioral Interventions by Chief Complaint
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Sluggish, Irritable, Amotivated
Avoidant, fearful, anxious
Busy Body, busy brain
Questions?
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