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10/24/2019
1
PediatricPsychopharmacology:TheSchoolPsychologist’sRolein
CollaboratingwiththeMedicationTeam
ARLENE ORTIZ , PHD, NCSP & EMILY C . HARANIN , PHD, NCSP
CAL IFORNIA ASSOC IAT ION OF SCHOOL PSYCHOLOGISTS ANNUAL CONFERENCE
LONG BEACH , CAOCTOBER 24 , 2019
ARLENE .ORTIZ@CSUS .EDU
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Objectives
Participantswillgaininformationaboutthegeneralstructureandproceduresofamedicationevaluationclinicinthecommunity.
Participantswilllearnabouthowtoeffectivelyengageinconsultationwithmedicationevaluationteammembers.
Participantswilllearntoidentifyhow,when,andwhytoseekoutmentalhealthprovidersintheircommunities
Participantswillbeexposedtocasestudiestoillustratekeypoints.
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ScheduleIntroductions
Overview&Need◦ PediatricMentalHealthNeeds◦ PsychotropicUse&EvaluationPractices
CHLAInterprofessional SchoolAgeClinic◦ SACTeam,Process,andPractices
BarriersandReasonsforCollaboration
TheSchoolPsychologistasLiaison
StrategiesforCollaboration
CaseStudy
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YourPresenters
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ArleneOrtiz,PhD,NCSPLicensedPsychologist
AssistantProfessorofSchoolPsychologyatCaliforniaStateUniversity,Sacramento◦ ProvidesassessmentsupervisiontograduatestudentsattheCenterforCounselingandDiagnosticServicesatCSUSandcounselingsupervisionatlocalelementaryschools.
◦ Completedatwo‐yearpostdocatChildren’sHospitalLosAngeles,UCEDDwhereshewasanactiveteammemberoftheSchoolAgeClinic,partneringwithfamiliesandmedicalproviderstohelpevaluatechildrenreferredforamedicationevaluation.
◦ Academicinterestincludeassessmentandinterventionpracticesforculturallyandlinguisticallydiverseindividuals.
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EmilyCHaranin,PhD,NCSPLicensedPsychologist
AssistantprofessorofclinicalpediatricsattheUSCKeckSchoolofMedicine,Children’sHospitalLosAngeles.
◦ Supervisionandtrainingofpredoctoral internsandpostdoctoralfellowsthroughCHLA’sAPA‐accreditedpsychologytrainingprograms.
◦ CoordinationofCHLASchoolAgeClinic(SAC),aninterprofessional medicationevaluationandmanagementclinic,embeddedwithinacommunitymentalhealthclinic.
◦ Mentoringofprofessionaltraineesofvariousdisciplinesinthedeliveryofinterprofessional services.
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PediatricMentalHealthNeeds
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20%of
childrenundertheageof18haveaCSHCN
of
familieshaveachildwitha
CSHCN
CSHCN=chronicphysical,developmental,behavioral,oremotionalconditionwhorequireservicesofanytypebeyondthatrequiresbychildrengenerally
ChronicSpecialHealthcareNeeds
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Gabe’sCareMap(Cristin Lind,2012)
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OurFocus
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MentalHealthDisordersinChildrenandAdolescents
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ofallchildrenandadolescents
21%
meetdiagnosticcriteriafora
mentalhealthdisorder
In2016,forU.S.children2‐17(usingNSCHdata)
9.4%hadbeen
diagnosedwithADHD
5.2%weretakingADHD
medication
Danielsonetal.2016.Prevalenceofparent‐reportedADHDdiagnosisandassociatedtreatmentamongUSchildrenandadolescents.JournalofClinicalChild&AdolescentPsychology.
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2016:AmongChildrenwithADHD(2‐17),77%WereReceivingTreatment(NSCH;Danielsonetal,2016)
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MedicationOnly30%
BThxOnly15%
Medication&Therapy32%
Neither23%
Treatment
Danielsonetal.2016.Prevalenceofparent‐reportedADHDdiagnosisandassociatedtreatmentamongUSchildrenandadolescents.JournalofClinicalChild&AdolescentPsychology.
OtherCommonBehavioralHealthDiagnosesByAge
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PrevalenceofPrescriptionMedicationUse
Psychopharmacologicalagentsusedinthelast30daysbychildrenyoungerthan18(2007to2010)◦ Stimulants:4.2% (CDC)◦ SSRI’s(antidepressants):1.2‐2%
Useofantipsychoticsformanagingdisruptivebehaviorinyoungchildrenisincreasing
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PediatricPsychopharmacology– ThingstoConsiderUsedtotargetspecificsymptomsratherthandiagnoses◦ Ex:Thereareover15medicationsthattreat“ADHD”
Medicationsvarywidely◦ Half‐life◦ Shortvslongacting◦ Potentialsideeffectsandbenefits
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CommonADHDMedications
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VariationinMedicationEvaluations
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VariabilityBasedonPrescriberandSetting
Psychiatrists Primary Care Providers
Developmental Behavioral
Pediatrician
Other Specialists
• Prescriberscomefromavarietyofdisciplines,eachwithdifferenttraininganddiverseprofessionalculturesandvalues.
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AACAPGuidelines2009
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GuidingPrincipalsforPediatricMedicationEvaluationsMedicationshouldbeconsideredwhenthepotentialbenefitsoutweighthepotentialrisks
Athoroughevaluationisessentialtoclarifydiagnosisandsymptomsthatwillbetargeted
Collaborationwithotherprofessionalsisrecommendedto◦ obtaincollateralinformation◦ makeaplanformonitoringoutcomes
Providefeedbacktochildandfamily(diagnosis,symptoms,plan,alternatives,risks)
Obtainsparent/guardianconsentandchildassent
Ateamapproachcanreduceoverprescribingthrough◦ Rulingoutalternativecauses◦ Providinglinkagetoalternativesupportsandservices◦ Promotingcoordinationamongfamilies,schools,specialtycare,andgeneralpediatrics
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SchoolAgeClinicatCHLACommunityMentalHealthCenter
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SACInterprofessionalTeam
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Nursing
Psychology
DBPOT
Speech
Case Manager
SACBasicInterprofessionalMedicationEvaluationProcess
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Referral
Step1TeamTriageVisit(Psychology&OT)
(SLP,CM)
Step2MedEval Visit(DBP&S1team)
(Nurse)
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Referral– “Ricky”8yearoldmale,3rd grade
ReferralConcern:verbalandphysicalimpulsivityathomeandschool,suspectedADHD(hasIEPunderOHI),family“hesitant”aboutmedication
TherapistConsult:additionalconcernsregardinganxiety,avoidstasksthatrequirewriting,half‐brother(age13)joinedfamilythreemonthsago
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Step1‐ GoalsStep1‐ Goals◦ Clarifyreferralconcernandtargetsymptoms◦ Assesssymptomsandcontributingfactors◦ Identifyandassesscurrentsupports/services◦ Assessinterest/readinessformedication◦ Identifyneedforadditionalinformation
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Step1‐ PreparationTeamLeadresponsibilities◦ Reviewrecords◦ Consultwiththerapist◦ Identifygoalsforvisit◦ Preparematerials◦ Assignrolestoteammembers
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Step1Visit‐ RolesInterprofessionalIntake&Triage(ClinicAppt &FollowUp)◦ Interviews◦ ClinicalInterviews(Collateral&Client)
◦ Observations◦ Clinic,home,and/orschool
◦ DataGathering◦ Multi‐rater/multi‐setting
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SACInterprofessionalMedicationEvaluationProcess
ReferralStep1
IPTeamTriage
Step2
DBP+Team
Pre Step 1
Records Review
Therapist Consult
Plan Goals & Roles
During Step 1
Clinical Interviews (parent & child)
Data Review & Planning
During Step 2
Family Centered
Rx Evaluation
InformedConsent/ Assent
After Step 1
Additional Data
Additional Services
Linkage
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Barriersto&ReasonsforCollaboration
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BarrierstoCollaboration
Misunderstandingsabouttherolesandcapabilitiesofproviders
Limitedinterprofessional trainingexperiencesbetweenmedicalprovidersandeducators
Differentdefinitionsofdisability/diagnosisacrosssettings◦ Physicians:InternationalClassificationofDiseases(ICD‐10)andDSM5◦ Educators:IDEA&CaliforniaCodeofEducation,Title5
Differentapproachestosupportingchildren
Limitedresources
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WhyCollaborate
Toensurethatbothprofessionsunderstandeachother(Stuart&Goodslit,1996)
Medicalprovidersmaynotbefamiliarwiththespecialeducationprocessand/orschool‐basedinterventions
Educationsmaynotbefamiliarwithservices/interventionsofferedbylocalmedicalproviders
Providersmayusedifferentterminologyandhavedifferentperspectives
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WhyCollaborate
Toincreaseratesoftreatmenteffectivenessbytreatingthewholeindividual
Oftenchildrenpresentwithcomplexneedsthatrequireanetworkofsupport
Childrenwithspecialneedsrequirefourtoeighttimesasmuchtimeandserviceprovisionashealthychildren(InstituteforFamily‐CenteredCare,1995)
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SchoolPsychologists:EquippedtoServeasLiaisons
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SchoolPsychologists:ExpertsinChildren&YouthWithDisabilities
Schoolpsychologistareexpertsinchildrenwithneurodevelopmentaldisabilities(Shaw&McCabe,2008)
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SchoolPsychologists:ExpertsinAssessmentSchoolpsychologistreceiveextensivetraininginmeasurement,assessment,identification,andremediationoflearningproblems(Daly,Kral,&Brown,2008)
Familiarwithdiagnosticclassificationsystems
Familiarwithtoolsandproceduresusedtoevaluatebehavioraldisordersinchildren
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SchoolPsychologists:ExpertsinSystems&ConsultationSchoolpsychologistsaretrainedtofacilitatecollaborationbetweensettingsandsystems
Schoolpsychologistshaveknowledgeofvariedmodelsandstrategiesofconsultation,collaboration,andcommunicationtopromoteeffectiveimplementationofservices
Schoolpsychologistshaveknowledgeofessentialinformationthatwillenhanceanaccurateandinformedtreatmentapproachbythemedicalteam
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SuggestionsforCollaborationWithinandBetweenSystems
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CollaborationBetweenSystems:ValuetheExpertiseofOthersBothprofessionsmustacceptandunderstandsystemsfordisabilityidentification
Eachislegitimateandvalid
EngageinActivelistening
Demonstratecuriosity
Positivelyreinforceparticipation
Sendthankyounotes
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CollaborationBetweenSystems:GainKnowledge&ShareKnowledgeGainNewKnowledge◦ BeTakethetimetolearnthelanguageusedbymedicalproviders◦ LearnaboutcommontoolsusedbymedicalproviderstoassessforADHD,depression,andanxiety
◦ Learnaboutcommonmedicationsusedtotreatprevalentbehavioralhealthdisordersandassociatedsideeffects
ShareKnowledge◦ Providebriefinfographicofthespecialeducationand504processatyourschooltolocalmedicalagencies
◦ Provideresourcesoninterventionsavailableforgeneraleducationstudentstomedialagencies
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CollaborationBetweenSystems:RespectProfessionalBoundariesAcknowledgeindividualexpertise
Respectformalboundariesofthemedicalandeducationalprofessions(Drotar,1995)
Physiciansshouldrefrainfromdictatingschooleducationalplacementdecisionsoreducationaltechniques
Schoolsshouldrefrainfromsuggestingmedicationdecisionsormakingmedicaldiagnoses
Isitokayforaschoolpsychologisttomakethefollowingobservation:"Sinceshestartedtakinghermedication,Janehasbeenfallingasleepinclass“?
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CollaborationBetweenSystems:InviteParticipationHaveaninformalprocessthatreachesacrossbarriers
Considermakingsmallrequeststhatmayhelpyoubetterservicethestudent
Inviteotherstoreviewreportsand/orprovidewritteninputregardingastudent'sprogress
e.g.,InviteapediatriciantoreviewtheIEPforanyactivitiesthatmaybemedicallycontraindicated.
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EffectiveCommunication:Within&BetweenSystemsReturnphonecallsinatimelymanner
Makeyourselfavailablebyphone,fax,ande‐mail
Identifyingandcommunicatingwhenyou’reavailable
Communicateinajargon‐freemanner
Developabrieffactsheetthatoutlinesyourschool'sgeneralapproachtocollaboratingwithhealth‐careprovidersandincludescontactinformationforappropriatestaffmembers
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EffectiveCommunication:BetweenSystemsInformationtoSharewithProviders◦ Specificbehaviorsofconcern,useobjectiveterms◦ Onsetofbehaviors◦ Frequency,Intensity,Duration◦ Precipitatingevents◦ Consequences◦ Supportsavailabletochildandfamily◦ Priorinterventions:lengthofservices,treatmentgoals,progress
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EffectiveCommunication:BetweenSystemsAdoptamedicalmodelofcasepresentation◦ Helpstoorganizelargequantitiesofinformationintothepertinentpositivesandnegatives◦ Leaveoutalljudgmentsandinformationthatarenotessential
OpeningStatement◦ Patient'sname,age,ethnicorigin,sex,andreasonforreferral
Addressallrelevanthistoricalfindings◦ Suchasbirthtrauma,historyofbraininjury,developmentaldelays,academicprogressovertime,orplacementinspecialeducation
Listrelativestrengthsandweaknessesofthestudent
ClassroomRequirements:Identifythebehavior,cognitive,social,andacademicrequirements
Reviewrelevantevaluationresults◦ Listthetopthreeorfourrecommendationsthatwillhelpthestudentandshouldbeaddressedbythephysician
◦ Shareotherareasofneedthatarebeingaddressedbytheschool.
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EffectiveCommunication:WithinSystemsEngagingParents◦ Parentsareviewedasexpertsoftheirchildren◦ Needtounderstandfamilyvaluesandbeliefs◦ Parents/legalguardiansmustcompletereleaseformsandunderstandthenatureofthecollaboration
◦ Helpparentsunderstandvalueofcollaborationacrosssystems
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EffectiveCommunication:WithinSystemsSharingbehavioralhealthconcernswithparents◦ Startconversationsearly◦ Beginwithchildstrengths◦ Describebehaviorsofconcern◦ Obtainparentinputrelatedtobehaviorsathomeorinthecommunity◦ Explainhowbehaviorsmaybeimpedingacademic/therapuetic progress◦ Encourageguardianstomonitorbehavior&follow‐upifneeded◦ Indicatecontinuedconcernsduringfollow‐updiscussion,afterbehavioralinterventionshavebeenattemptedwithfidelity.Provideparentswithspecificinformationrelatedtointerventionsattemptedandstudentoutcomes.
◦ Informfamilythatamedicalprofessionalmaybeabletoofferrecommendationsrelatedtotreatmentofobservedbehaviors,suchasmedicationandmaywarrantconsideration
◦ Endwithchildstrengths
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CaseStudy
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CaseStudyHowwouldyougoaboutcollaboratingwithDavid’smedicationteam?
Utilizingamedicalmodel,howwouldyoudiscussDavid’scasetotheteam?
Whatinformationwouldyouneedtoaccomplishthisgoal?
WhatinformationwouldyouliketoobtainfromDavid’smedicalteam?
Identifysharedgoalsamongprofessionals.Howwillthesebeaccomplished?Whataretheresponsibilitiesforeachprofessional.
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Questions?
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WhereToGoForMoreInformationonMedicationAmericanAcademyofPediatrics:https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Understanding-ADHD.aspx
CenterforDiseaseControl&Prevention:https://www.cdc.gov/ncbddd/adhd/treatment.html
ChildrenandAdultswithAttention‐Deficit/HyperactivityDisorder:https://chadd.org/for-parents/medications-used-in-the-treatment-of-adhd/
AmericanPsychologicalAssociation:https://www.apa.org/pi/families/resources/child-medications.pdf
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AdditionalResourcesSocietyforDevelopmentalandBehavioralPediatrics:◦ https://www.sdbp.org/about‐us/behavioral‐pediatricians.cfm
MentalHealthAmerica:◦ https://www.mentalhealthamerica.net/sites/default/files/BACK_TO_SCHOOL%202014_Childrens_Mental_Health_Matters_Smaller.pdf
TreatmentofChildrenwithMentalIllness:◦ https://www.nimh.nih.gov/health/publications/treatment‐of‐children‐with‐mental‐illness‐fact‐sheet/nimh‐treatment‐children‐mental‐illness‐faq_34669.pdf
CAMentalHealthServicesDivision:◦ http://www.dhcs.ca.gov/services/mh/Pages/ProgramsforChildrenandYouth.aspx
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SelectReferencesDrotar,D.(1995). Issuesinclinicalchildpsychology.Consultingwithpediatricians:
Psychologicalperspectives. NewYork,NY,US:PlenumPress.
Mayne,S.L.,etal.(2016).Variationsinmentalhealthdiagnosisandprescribingacrosspediatricprimarycarepractices.Pediatrics,137, e20152974;doi:10.1542/peds.2015‐2974
Merikangas,K.R.,He,J.,Burstein,M.,Swanson,S.A.,Avenevoli,S.,Cui,L.,Benjet,C.,Georgiades,K.,&Swendsen,J.(2010).LifetimeprevalenceofmentaldisordersintheUSadolescents:Results fromtheNationalComorbidityStudy‐AdolescentSupplement.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry,49,980‐989.
Shaw,S.R.,Clyton,M.C.,Dodd,J.L.,&Rigby,B.(2004).Collaboratingwithphysicians:Aguideforschoolleaders.PrincipalLeadership,5,11‐13.
Shaw,S.R.,&McCabe,P.C.(2008).Hospitaltoschooltransitionforchildrenwithchronicillness:Meetingthenewchallengesofanevolvinghealthcaresystem.PsychologyintheSchools,45,74–87.
Shaw,S.R.,&Woo,A.H.(2014).Bestpracticesincollaboratingwithmedicalpersonnel.InJ.P.L.Harrison&A.Thomas(Eds.),Bestpracticesinschoolpsychology:Systems‐levelservices (pp.375‐388).Bethesda,MD:NationalAssociationofSchoolPsychologists.
Stancin,T.,&Perrin,E.C.(2014,May‐June).Psychologistsandpediatricians:Opportunitiesforcollaborationinprimarycare.AmericanPsychologist,69,332‐242.
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