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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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