PSP Child and Youth Mental Health

PSP Child and Youth Mental Health
<?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> PSP master PowerPoint template specifications Font throughout: Myriad Pro Title font colour: RGB All text font colour: RGB Title slide: Title: 44 font Speaker: 32 font Place and date: 20 font Content slide (positions from top left corner): Title: 32 font; title text box: horizontal 0.56” vertical 0.25” Main text box: horizontal 0.56” vertical 0.25” Footnote: 12 font; horizontal 0.56” vertical 7.25” Font sizes and bullets: see slide 2 PSP slide master specifications Title and ending slides Position of graphics and text from top left corner: Top graphic: horizontal -.01” vertical 0.05” Bottom graphic: horizontal 0” vertical 8.16” PSP logo: horizontal .84” vertical 1” GPSC logo: horizontal 4.49” vertical 7.19” Master title: horizontal 0.56” vertical 3.5” Speaker: horizontal 0.56” vertical 5.08” Date and place: horizontal 0.56” vertical 5.92” Information box: horizontal 1.64” vertical 3.17” Main slides: PSP logo: horizontal 9.28” vertical 7.18” Page number: horizontal 10.14” vertical 7.72” PSP Child and Youth Mental Health Learning Session 2 Presenters name here Location here Date here © 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher. Health educators and health providers are permitted to use this publication for non-commercial educational purposes only. No part of this publication may be modified, adapted, used for commercial or non-educational purposes without the express written consent of the BCMA and Dr. Kutcher.

Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd Consulting Fees: MedX Group Inc. Other: Employee of XYZ Hospital Group Please fill out all applicable areas (highlighted in red). One slide per speaker.

Disclosure of Commercial Support
This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. Please fill out all applicable areas (highlighted in red).

Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to the College of Family Physicians of Canada’s “Quick Tips” document. Please fill out all applicable areas (highlighted in red). Please visit the following link for the CFPC’s “Quick Tips” document:

Some info A few housekeeping items: cells, washrooms. We know emergencies sometimes come up, please feel free to leave the room if you need to take a call The agenda is on the table in front of you. Of importance you will note we are having a break for coffee around: (time) Housekeeping washrooms and nearest fire exist Ground rules Respect all ideas and opinions Share experiences with your peers On time back from break Cell phones on mute or vibrate?

Agenda Sharing and Learning from the Action Period.
Identify, assess, treat and manage children and adolescents for Anxiety. Identify, assess, treat and manage adolescents for Depression. Medications for Depression / Anxiety. MOA role (to be created by PSP Coordinators). Planning for the Action Period. Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders 6

Sharing the Learnings from the Action Period
Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders

CYMH Roles & Referrals Mental Health Screening Questions
Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders

Mental Health Screening Q’s
Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? If YES – consider a depressive disorder Apply the KADS evaluation Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? If YES – consider an anxiety disorder Apply the SCARED evaluation Proceed to the Identification, Diagnosis and Treatment of Child and Adolescent Anxiety Disorders Module Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders 9

Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If YES – consider ADHD Apply the SNAP-IV evaluation Proceed to the Identification, Diagnosis and Treatment of the Child and Adolescent ADHD Module If the answer to question 3 is YES – consider ADHD, apply the SNAP evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth ADHD Module NOTE: Note that some cases of anxiety and depression may demonstrate positive scores on the concentration component of the SNAP. If no hyperactivity components are identified on the SNAP review for ADHD, please assess for depression and anxiety using KADS and SCARED. by Boaz Yiftach

4. There has been a marked change in usual emotions, behaviour, cognition or functioning (based on either youth or parent report) If YES – probe further to determine if difficulties are ongoing or transitory. Consistent behaviour problems at home and/or school may warrant referral to Strongest Families. If the answer to question 4 is YES, probe further to determine whether the difficulties are on-going or transitory. Problem behaviours that occur erratically typically do not warrant treatment. Consistent behaviour problems at home and/or school may warrant referral to Strongest Families. by Boaz Yiftach

Adolescent Major Depressive Disorder (MDD)
Fast Facts: Adolescent Depression Adolescence = puberty to mid-twenties Affects approx. 6-8% of adolescents Most experience 1st episode between yrs old Youth onset usually = chronic condition Substantial morbidity Poor economic/vocational/interpersonal/health outcomes Increased mortality Suicide Other long term chronic illness: diabetes, heart disease, etc. Early identification & early effective treatment Decreases short-term morbidity Improves long-term outcomes Decreased mortality

Depression Screening Question
Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? If YES – consider a depressive disorder Apply the KADS evaluation Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders 13

Key Steps for Treatment of MDD in Adolescents
Identification of youth at risk for MDD Screening & diagnosis in the clinical setting Treatment template Suicide assessment Contingency planning Referral flags Key Steps 1. Identification of youth at risk for MDD 2. Useful methods for screening and diagnosis of MDD in the clinical setting 3. Treatment template 4. Suicide assessment 5. Safety/contingency planning 6. Referral flags

Step 1: Major Depressive Disorder in Youth Risk Identification Table
Well established and significant risk effect Less well established risk effect Possible “group” identifiers (these are not causal for MDD but may identify factors related to adolescent onset MDD) 1. Family history of MDD 2. Family history of suicide 3. Family history of a mental illness (especially a mood disorder, anxiety disorder, substance abuse disorder) 4. Childhood onset anxiety disorder 1. Childhood onset ADHD 2. Substance abuse 3. Severe and persistent environmental stressors (sexual abuse, physical abuse, neglect) in Childhood. 4. Head injury (concussion) 1. School failure 2. Gay, lesbian, bisexual, transsexual 3. Bullying (victim and/or perpetrator) Identification of Youth at Risk for MDD First contact health providers are in an ideal position to identify youth who are at risk to develop depression. The following table has been compiled from the scientific literature and is presented in a format that can be efficiently used by a health provider to identify those young people who should be periodically monitored for onset of MDD.

Clinical Major Depressive Disorder Screening in Primary Care
Who to Screen? Adolescents with: Risk factors Persistent low mood Recent onset Academic problems/failure Substance misuse Suicidal ideation Clinical Screening for Adolescent Depression in the Primary Care Setting Clinical screening can be effectively and efficiently conducted by primary care providers who are often the first point of contact for concerned parents or school authorities and who may know the child and family well. Clinical screening may be useful to identify patients who may have ADHD – individuals who are more likely to have the disorder. Conducting this brief screening question may allow you to recognize if further ADHD investigation is needed or not. These questions can be used de-novo or they can be applied after the initial screening described at the beginning of this module. Who to screen? • Child presenting with symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems. • Child with numerous complaints about their behavior from teacher or parents which are not easily explained by a known physical illness and which vary in duration, frequency and intensity over a long period of time. • Child at risk: see Risk Identification Table. Refer to Child and Adolescent Mental Health Screen Questions. These questions can be included in clinic/office registration materials to be completed by parents or patients before visits or in the waiting room before the evaluation screening. Refer to Risk Identification Table Stockxchng ID: 63460_4774

Methods for Clinical Screening & Diagnosis
Kutcher Adolescent Depression Scale (KADS-6) Screen at clinical contacts Including contraception & sexual health visits Useful Methods for Screening and Diagnosis As youth generally visit health care providers infrequently, screening should be applied to both high risk and usual risk youth at scheduled clinical contacts. Teen visits for contraception or sexual health issues provide an excellent opportunity to screen for depression. A simple self-test with good sensitivity and specificity should be used. The 6-item Kutcher Adolescent Depression Scale (6-KADS) has been tested in population samples and demonstrated excellent sensitivity and specificity. It is recommended for use in both the NICE and GLAD-PC guidelines. It can be filled out by the young person prior to a face-to-face discussion with the health provider and is available in a number of different languages. When the KADS is provided to the young person for the first time, the clinician should take time to ensure that the youth understands the purpose of using the tool and how the KADS should be completed. When reviewing the KADS please ensure that you provide the young person with feedback on their results. Explain purpose of test & give feedback on results ID:983365

KADS Score of 6+ Strongly encourage and prescribe: 1st appointment:
Discuss issues in youth’s life & environment Use TeFA – Teen Functional Activities Assessment Problem solving assistance Use PST – Psychotherapeutic Support for Teens as a guide Strongly encourage and prescribe: Positive Social Activities Exercise Regulated Sleep Regulate Eating If a KADS score of 6 or higher is found during screening the following is suggested: Discussion about important issues/problems in the youth’s life/environment. Complete or use the Teen Functional Activities Assessment (TeFA) to assist in determining the impact of the depression on the teens functioning. Supportive, non-judgmental problem solving assistance – “supportive rapport” (use the Psychotherapeutic Support for Teens (PST) as a guide to this intervention) – strongly encourage and prescribe: exercise; regulated sleep; regulated eating; positive social activities Screen for suicide risk - use the Tool for Assessment of Suicide Risk (TASR)

KADS Score of 6+ 1st appointment (continued) Screen for suicide risk
Use TASR – Tool for Assessment of Suicide Risk ‘Check-in’ 3 days following initial appointment Via telephone (3 – 5 mins), text message or If problems continue, book appointment ASAP If a KADS score of 6 or higher is found during screening the following is suggested: (cont’d) Telephone “check in” scheduled for 3 days from visit (3-5 minutes) – text message or may be preferred by the adolescent. If a problem is identified ask the young person to come for an appointment as soon as possible. Mental health check-up with KADS completion 1 week from visit. This visit could also include the TeFA and PST so schedule about minutes Another telephone “check in” at three days following the second visit (3-5 minutes) A third visit 1 week later during which the KADS & TeFA are completed.

KADS Score of 6+ 2nd appointment Mental health checkup 15 – 20 minutes
1 week from first visit Include: KADS, TeFA, PST Monitor suicide risk 3rd appointment 1 week from 2nd mental health checkup Include: KADS & TeFA If a KADS score of 6 or higher is found during screening the following is suggested: (cont’d) Telephone “check in” scheduled for 3 days from visit (3-5 minutes) – text message or may be preferred by the adolescent. If a problem is identified ask the young person to come for an appointment as soon as possible. Mental health check-up with KADS completion 1 week from visit. This visit could also include the TeFA and PST so schedule about minutes Another telephone “check in” at three days following the second visit (3-5 minutes) A third visit 1 week later during which the KADS & TeFA are completed. by Nutdanai Apikhomboonwaroot

Don’t Get Overwhelmed!! Don’t get overwhelmed! Use the tools
Use the tools Address important issues Three -15 minute office visits Use KADS routinely Suicide intent/plan/attempt = Emergency Mental Health Assessment Yes there are a number of clinical tools and they address important issues in diagnosis and treatment of adolescent major depressive disorder. However a full assessment of MDD can be completed in three 15 minute office visits using the suggested framework above. Some clinicians may prefer to integrate the details found in the tools into their assessment interviews rather than using the tools separately. However, the KADS should be routinely utilized at every visit as a symptom monitoring strategy. Dreamstimefree

MDD Highly Probable if…
KADS scores remain at 6+ For over 2 weeks At each of the three assessment points Suicidal thoughts or self harm behaviors School, family or interpersonal functioning declines Assess using TeFA If above occurs, on 3rd visit complete KADS-11 item Five or more items score 2+ = diagnosis of MDD Initiate treatment plan MDD Diagnosis is highly probable if: KADS scores remain at 6 or greater over the two week period (at each of the three assessment points) Persistent suicidal thoughts or self-harm behaviours occur School, family or interpersonal functioning declines (this can be assessed by using the TeFA) If this occurs, the KADS-11 item should be completed at the third visit. If five or more items are scored as a 2 or greater using this tool, a diagnosis of MDD can be made and treatment planning initiated.

Visit 2 Visit 1 Visit 3 Phone, Email or Text Phone, Email or Text
If KADS is 6 or greater or TeFA shows decrease in function – proceed to steps 2 and 3 Visit 1 KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse give instructions to call if suicide thoughts or plans or acts of self-harm occur - screen for depression TASR-A CONTACT Phone, or Text If KADS remains > 6 or TeFA shows decrease in function – proceed to steps 4 and 5 Visit 2 KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse – give instructions to call if suicide thoughts or plans or acts of self-harm occur. Clinical Approach to Possible Adolescent MDD in Primary Care* * Alternatively, some health care providers may choose to “flush out” the patient’s entrance complaint, determine if any safety or immediate referral issues are present (for example: suicidal; psychotic – see below for more details), provide the KADS to the patient to complete and then schedule a longer visit in the near future to complete the assessment. The key issue here is to ensure patient safety while providing a long enough assessment period to allow for distress to be better differentiated from disorder. CONTACT Phone, or Text Visit 3 If KADS remains > 6 or TeFA shows decrease in function – proceed to diagnosis (KADS 11) and treatment KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if suicide thoughts or plans or acts of self-harm occur

Additional Psychosocial Interventions
CBIS Depression CBT/IPT tools Evidence based psychotherapies available (CBIS) Application recommended – manual provided Can be implemented at any time during the process Education about medications should be added by Idea Go

Dealing with Depression
who is DWD for: Youth with low mood (or depression) Youth at risk of low mood or depression Concerned parents or caregivers Peers & family Concerned adults (school personnel, counsellors, EFAP providers) Health providers (family physicians, nurses, youth and family workers) Mental Health Specialists

Confident Families: Thriving Kids
Children aged 3 to 12. Physician referral. No cost to patients. Via telephone. Operational hours include evening and weekend. Strongest Families BC is an evidence-based, educational and coaching intervention for disruptive behaviour and/or attention deficits in children aged 3 to 12 Offered by the Canadian Mental Health Association – BC Division at no cost to patients This is a new program, delivered via telephone, which works with parents/caregivers in the comfort and privacy of their own home The program has proven successful in reducing impulsivity, improving attention and conduct as well benefiting overall child and family functioning Hours of operation include evening and weekend hours thus eliminating the need for time away from work and school Access to the program requires a physician referral; The referral form is in your binder

Table Discussion How can these tools fit into practice workflow? What about applicability to school or other practice environments? (for example screening tools) How can other team members use the information from these tools? How can information from other environments be used to complete them? How can team members in non-providers roles contribute to administration and completion of these tools?

Childhood & Adolescent Anxiety
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Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? If YES – consider an anxiety disorder Apply the SCARED evaluation Proceed to the Identification, Diagnosis and Treatment of Child and Adolescent Anxiety Disorders Module Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders 29

Use of SCARED in Assessment
Anxiety disorder is suspected: if score of 25 or higher Use of the SCARED in the assessment of Anxiety Disorder in Children The SCARED is a self-report instrument that can be helpful in the diagnosis and monitoring of anxiety disorders in children. Information on scoring of the SCARED is found on the instrument itself. An anxiety disorder in a child should be suspected if a SCARED score of 25 or higher is found at time of evaluation. A high SCARED score (25 or higher) does not mean that a patient has a clinical anxiety disorder; it simply suggests a possible diagnosis and the score/items can be used as a guide for further questioning. Anxiety Disorder is Suspected If a SCARED score of 25 or higher is found during screening the following is suggested: Discussion about important issues/problems in the child’s life/environment. Ask about school, home, activities, friends and family. Anxiety disorders interfere in normal developmental tasks and functioning. Supportive, non-judgmental problem solving assistance – “supportive strategies” for parents. A child’s anxiety can significantly impact the family. Parents will often accommodate their child’s anxiety in order to maintain overall family functioning. General self-care of parent and child is important as this decreases overall stress. Strongly encourage and prescribe: regular and adequate sleep; physical activity; healthy eating; positive social activities and supports for primary caregiver. 30

Visit 2 Visit 1 Visit 3 Phone, Email or Text Phone, Email or Text
If SCARED is 25 or greater (parent and/or child) or shows decrease in function, review WRP/Stress management strategies and proceed to step 2 in 1-2 weeks. Visit 1 SCARED Function Use PST & MEP as indicated and as time allows If SCARED < 25 and/or shows no decrease in function, monitor again (SCARED) in a month. Advise to call if feeling worse or any safety concerns. CONTACT Phone, or Text If SCARED > 25, and shows decrease in function, utilize PST strategies, review WRP and proceed to step 3 within a week. Visit 2 SCARED, Function. Use PST & MEP If SCARED <25 and shows no decrease in function, monitor again in a month. Advise to call if feeling worse or any safety concerns. Visit 1, 2 & 3: Clinical Approach to Possible Anxiety Disorder in Children in Primary Care Setting * Alternatively, some health care providers may choose to “flush out” the child’s entrance complaint, determine if any safety or immediate referral issues are present (for example: not eating; not leaving house; suicidal – see below for more details), provide the SCARED and CESDC to the parent and child to complete and then schedule a longer visit in the near future to complete the assessment. The key issue here is to ensure patient safety while providing a long enough assessment period to allow for distress to be better differentiated from disorder. . CONTACT Phone, or Text Visit 3 If SCARED remains > 25 or shows decrease in function, proceed to diagnosis (DSM-IVTR criteria) and treatment SCARED, Function. Use PST & MEP If SCARED <25 and shows no decrease in function, monitor again (SCARED) in one month. Advise to call if feeing worse or any safety concerns.

Teen Anxiety Disorder is Suspected
SCARED score is 25 or higher Discuss issues/problems in the youth’s life/environment. Teen Functional Activities Assessment (TeFA) Supportive, non-judgmental problem solving assistance – Psychotherapeutic Support for Teens (PST) as a guide Strongly encourage and prescribe: Exercise Regulated sleep Regulated eating Positive social activities Mental Health Screening Questions Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders 32

Psychotherapy First line treatment Cognitive Behavioral Therapy (CBT)
Barriers to CBT Long waiting lists, psychotherapies not available Family cannot access services If barriers to CBT Implement medications, wellness enhancing activities and supportive rapport Monitor outcome regularly: refer if no change or worse Standard anxiety disorder treatment guidelines recommend the use of cognitive behavioural therapy (CBT) as first line treatment for children with anxiety disorders Cognitive Behavioural Therapy (CBT) is a strong evidence based practice whereby children often have improvement in their anxiety with CBT alone, and do not require medication intervention. However, if waiting lists for these therapies are long, these psychotherapies are not available, or the family is not able to access services, treatment may need to be implemented with medications, wellness enhancing activities and supportive rapport.

Pharmacological Treatment of Adolescent Depression/Anxiety Disorder Children & Adolescents
Fast Facts: Adolescent Depression Adolescence = puberty to mid-twenties Affects approx. 6-8% of adolescents Most experience 1st episode between yrs old Youth onset usually = chronic condition Substantial morbidity Poor economic/vocational/interpersonal/health outcomes Increased mortality Suicide Other long term chronic illness: diabetes, heart disease, etc. Early identification & early effective treatment Decreases short-term morbidity Improves long-term outcomes Decreased mortality

Psychosocial Interventions
Cognitive Behavioural Therapy (CBT) *** REMINDER THAT PSYCHOTHERAPY TO BE TRIED FIRST *** Psychotherapy Standard anxiety disorder treatment guidelines recommend the use of Cognitive Behavioural Therapy (CBT) as first line treatment for children with anxiety disorders. Cognitive Behavioural Therapy (CBT) is a strong evidence based practice whereby children often have improvement in their anxiety with CBT alone, and do not require medication intervention. However, if waiting lists for these therapies are long, these psychotherapies are not available, or the family is not able to access services, treatment may need to be implemented with medications, wellness enhancing activities and supportive rapport. There are also some CBT strategies that can be provided through primary care (see Psychotherapeutic Support for Children and Parents below). Additionally, there are some cognitive behavioural self help resources for parents of children with anxiety that provide helpful education and practical skills and tools for parents to help their child better manage anxiety. Remember that although suicidal ideation and suicide attempts are not as common in childhood anxiety disorders, they may occur, and should be monitored in any treatment modality. Additionally, evidence suggests that CBT has additional positive effects when combined with a medication treatment in severe anxiety disorders. For example, the addition an SSRI to CBT increases the numbers of children in treatment that no longer meet criteria for an anxiety disorder. by Master Isolated Images

Medication Intro Medication Intro:
Provide rationale, expectations & education Explain how medication works Warn of potential side effects Health Canada Warnings Suicidal thoughts and behaviors Provide timeline Titration Treatment response Psychotherapeutic Support for Teens with Anxiety Medication Intro Provide rationale for medication trial, what they can expect, and education about medication. Explain how medication works to treat anxiety. Give information about potential side effects and Health Canada Warning regarding increase risk of suicidal thoughts and behaviours in youth 18 and under taking antidepressant medication. Provide time line for titration of medication and treatment response. by Scottchan

Do not rush into medication subscribing!
Do not use to treat mild symptoms or for “usual” stress An Important Clinical Point: Medications should not be used to treat children who have mild to moderate symptoms of anxiety or stress. They should be used only for treating moderate to severe anxiety disorders, and usually in those children with significant impairment in functioning. If you are not sure if it is an anxiety disorder, it is reasonable to offer supportive rapport, suggest wellness enhancing activities and stress management strategies, and monitor carefully for symptom change and suicide risk. Do not rush into medication prescribing. Use medications for where they are clinically indicated: in severe and unremitting anxiety disorders. by Salvatore Vuono

Antidepressants Not all anxiety or depressive disorders require medication Recommended first line treatment: Cognitive Behavioral Therapy Approach e.g. CBIS Selective serotonin reuptake inhibitors (SSRI): Fluoxetine or Sertraline If not tolerable refer child to mental health services Medication should not be used alone: Anxiety and mood management strategies Antidepressants in Childhood Anxiety Disorders Both CBT and pharmacological management are evidence based treatments in childhood anxiety disorders. In moderate to severe anxiety disorders, and when children are not able to engage or utilize CBT strategies, the addition of medication can be helpful. The best level one evidence for medication treatment of childhood anxiety disorders is the selective serotonin reuptake inhibitors (SSRI). There is minimal evidence for use of medication in children under the age of 7 years. Cognitive behavioural therapy in combination with SSRI is the recommended first line treatment for moderate to severe anxiety disorders (including OCD). We recommend that either fluoxetine or sertraline be the first line medication treatment for childhood anxiety in primary care based on scientific evidence base, side effects and half life profile, and ease of use. If a child does not tolerate an initial trial or there is no improvement, the youth should be referred to secondary/tertiary mental health services. Not all anxiety disorders require treatment with medication, and we strongly recommend medication not be used alone. Medication should be viewed as helping the child decrease overall anxiety so they can successfully learn and utilize anxiety management strategies, with the long term goal of no longer needing medication. ID stockxchng

Antidepressants Combine with: CBT Support Education
Self Help Strategies Antidepressents (cont’d) Given the side effects and risks of SSRI medication in children, and the limited long term safety data of these medications in the developing brain, medication intervention should be combined with CBT, wellness enhancement activities and supportive rapport. Alternatively it could be combined with anxiety disorder education (and parent self help strategies), wellness enhancement activities and supportive rapport. Fluoxetine and sertraline can significantly improve anxiety symptoms and improve depressive symptoms if they are also present. However, some children may experience suicidal ideation and self harm behaviour or have these increased when treated with antidepressant medication. Therefore systematic assessment of suicide risk must be completed as part of the ongoing treatment with antidepressants (see Health Canada Advisory for antidepressant medication). Further information on SSRI use and youth suicide can be accessed below. We suggest that if fluoxetine, sertraline or another SSRI is used, the following 12 steps of treatment be considered, customized and integrated into a practical approach that is feasible in your practice. Wellness Activities

Antidepressants in Childhood
Minimal evidence in < 7 yrs SSRI’s: Fluoxetine Sertraline Do not use alone Suicidal ideation & self harm behavior Antidepressants in Childhood Anxiety Disorders Both CBT and pharmacological management are evidence based treatments in childhood anxiety disorders. In moderate to severe anxiety disorders, and when children are not able to engage or utilize CBT strategies, the addition of medication can be helpful. The best level one evidence for medication treatment of childhood anxiety disorders is the selective serotonin reuptake inhibitors (SSRI). There is minimal evidence for use of medication in children under the age of 7 years. Cognitive behavioural therapy in combination with SSRI is the recommended first line treatment for moderate to severe anxiety disorders (including OCD). We recommend that either fluoxetine or sertraline be the first line medication treatment for childhood anxiety in primary care based on scientific evidence base, side effects and half life profile, and ease of use. If a child does not tolerate an initial trial or there is no improvement, the youth should be referred to secondary/tertiary mental health services. Not all anxiety disorders require treatment with medication, and we strongly recommend medication not be used alone. Medication should be viewed as helping the child decrease overall anxiety so they can successfully learn and utilize anxiety management strategies, with the long term goal of no longer needing medication. Given the side effects and risks of SSRI medication in children, and the limited long term safety data of these medications in the developing brain, medication intervention should be combined with CBT, wellness enhancement activities and supportive rapport. Alternatively it could be combined with anxiety disorder education (and parent self help strategies). Fluoxetine and sertraline can significantly improve anxiety symptoms and improve depressive symptoms if they are also present. However, some children may experience suicidal ideation and self harm behaviour or have these increased when treated with antidepressant medication. Therefore systematic assessment of suicide risk must be completed as part of the ongoing treatment with antidepressants (see Health Canada Advisory for antidepressant medication). Further information on SSRI use and youth suicide can be accessed below. We suggest that if fluoxetine, sertraline or another SSRI is used, the following 12 steps of treatment be considered, customized and integrated into a practical approach that is feasible in your practice. by Tungphoto

12 Steps to SSRI Treatment
Do no harm Ensure diagnostic criteria are met Check for other psychiatric symptoms/stressors Check for agitation, panic or impulsivity Check for family history of mania or bipolar Measure patients current somatic symptoms before beginning treatment: Restlessness, agitation, stomach upset, irritability 12 Steps to SSRI Treatment Do not harm Do no harm. This does not mean—do not treat. This means do a proper risk benefit relationship analysis of the situation. And make sure that your evaluation of these risks and benefits has been fully discussed with your patient/ family. 2. Ensure diagnostic criteria are met Make sure the patient has an anxiety disorder. This means that the diagnostic criteria are clearly met and that there is clear-cut functional impairment and/or significant distress. Medications should not be used to treat anxiety symptoms, they should be reserved for the treatment of moderate to severe anxiety disorders. Remember that threshold for diagnosis is not only within the total number of criteria met in the syndrome, but also within each criterion. For example, anxiety about upcoming move without any change in function would not qualify as excessive worry of at least 6 months duration. 3. Check for other psychiatric symptoms/stressors Check carefully for other psychiatric symptoms and stressors that might suggest a different disorder or different treatment approach. For example, does the child have a major depressive disorder, are the symptoms indicative of a learning disorder or bullying that can present with severe anxiety and isolation in the school setting. 4. Check for agitation, panic or impulsivity Check for symptoms of agitation, panic and impulsivity. If the patient has these symptoms they may be at greater risk for the behavioral adverse effects of an SSRI. 5. Check for family history of mania or bipolar disorder Check for a past history of mania and for a family history of bipolar disorder. Many youth who develop bipolar disorder report a preceding anxiety disorder diagnosis in childhood or teen years. Also, remember that up to two-thirds of teen onset bipolar disorders present to a mental health professional first with depression. Young people with this background may be more at risk for the behavioral activation effects of SSRIs. 6. Measure patients somatic symptoms before beginning treatment Measure the patient’s current somatic symptoms, paying careful attention to such items as restlessness, agitation, stomach upset, irritability and the like—before you begin treatment. A side effects scale (see below for an example) can be used to address this issue.

12 Steps to SSRI Treatment
Measure the symptoms: Pay special attention to suicidality. Provide comprehensive information: About disorder and treatment options. Provide family and child with SSRI info: Side effects & timelines to improvement. Start with small test dose of medication. Slowly increase dose. Take advantage of the placebo response. Rawich freedigitalphotos.net 12 Steps to SSRI Treatment (cont’d) 7. Measure the symptoms Measure the symptoms of anxiety, depression and pay special attention to suicidality. The SCARED is a self report scale for anxiety (see above link) and the CES-DC is a self report scale for depression (see below). Both are easy to use, validated in this population and can provide not only baseline but also treatment outcome information. Remember that SSRI’s may occasionally increase suicidal ideation so it is very important for your risk–benefit analysis to determine if there is suicidal ideation at baseline. 8. Provide comprehensive information Provide comprehensive information about the illness and the various treatment options to the patient and family. Appropriate literature should be available in your office and you should have a list of good websites to which you can direct their attention. Remember, the pharmacotherapy of anxiety is not emergency medical treatment. There is time for substantial research followed by frank and open discussion with the patient and family. 9. Provide family and child with SSRI Information If an SSRI is chosen make sure that you provide the patient and family with appropriate information about possible side effects (both behavioral and somatic) and the expected timelines to improvement. Ideally this should be in written form and if you are concerned about litigation have the patient and family sign one form and keep it in the patient record. Also make a note in the record as to the discussions and decision. 10. Start with small test dose of medication After doing the necessary laboratory workup as indicated by medical history and review of systems (for an SSRI there are no required blood tests, but some recommend a pregnancy test for females), start with a small test dose of the medication, preferably given at a time when the child is with a responsible adult who knows about the test dose and who can contact you if there is a problem. Following that begin treatment with a very low dose (often you can cut the smallest dose pill in half or you can have the parent separate a capsule’s contents, some medication comes in liquid form) and ask the patient and parent to monitor for adverse behavioral effects daily. Remember to provide a phone number where you can be reached if any problems develop and arrange to see the patient within about a week of initiating treatment. The medication should be kept by the parent in a safe place away from the child’s access. 11. Slowly increase dose Increase the dose slowly at no more than 1-2 week intervals until your initial therapeutic dose is reached (the expected minimally effective daily dose), then wait for the required 6—8 weeks at this dose to determine efficacy. Never prescribe medication without at least offering supportive wellness and stress management support, as well as some basic CBT strategies (if CBT is notavailable through services in your community). See the patient weekly for the first month and allow for telephone check–in whenever the dose is increased or between visits if concerns arise. Once stable on a dosage and no side effects over a month, then visits can decrease to every 2 weeks and gradually go to every month if doing well. If there is a dosage increase, the risk of side effects increases, and frequency of visits should go back to every week for a few weeks. Always check for and record possible adverse events at each visit (use the form that you used at baseline so that you can compare symptom changes over time) and assess improvement at Weeks 2, 4, 5 and 6. 12. Take advantage of placebo response Take advantage of the placebo response (found to be high in most child medication trials) That is, invoke a similar approach to patient care as done in studies including frequent face–to–face contact early in the course of therapy, the development of a trusting and supportive relationship, efforts to measure response objectively and subjectively, and careful elicitation of side effects, overall tolerance, ongoing concerns, and satisfaction with treatment. This approach represents good clinical care that is consistent with the “careful monitoring” advocated by the FDA and other organizations. This approach will not necessarily totally ameliorate the occurrence of behavioral side effects but it may cut down their prevalence and will help you quickly identify when they occur so that you can intervene appropriately.

Initiating Pharmacological Treatment
Fluoxetine Best level one evidence Do not use alone May increase… Suicidal ideation? Self harm Assessment of suicide risk ongoing Initiating Pharmacological Treatment for Adolescent Depression The best level one evidence for medication treatment of adolescent MDD is for fluoxetine. We recommend that this be the first line medication treatment for adolescent MDD in primary care and that other medication treatments be reserved for use by secondary/tertiary mental health services for those youth who do not respond or who cannot tolerate fluoxetine. However we also strongly recommend that fluoxetine is not used alone. Ideally it should be combined with CBT, wellness enhancement activities and supportive rapport. Alternatively it could be combined with IPT, wellness enhancement activities and supportive rapport. If neither CBT nor IPT is available fluoxetine could be combined with wellness enhancement activities and supportive rapport. Fluoxetine treatment significantly improves depressive symptoms and decreases suicidal ideation. However, some young people may experience suicidal ideation and self-harm attempts or have these increased when treated with fluoxetine. Therefore systematic assessment of suicide risk must be completed as part of the ongoing treatment with fluoxetine (see Health Canada Advisory for Fluoxetine). Further information on SSRI use and youth suicide can be accessed below. We suggest that if fluoxetine is used, the following 12 steps of treatment be considered, customized and integrated into a practical approach that is feasible in your practice. by Zole4

Fluoxetine Treatment START LOW & GO SLOW
Begin 5-10 mg/day for 1-2 wks (2.5-5 mg if significant anxiety symptoms) Liquid form: 2.5 – 5 mg/day; smaller increases Target dose 20 mg/day for min. 8 wks Expect continued improvement for a few months at same dose if initial response is positive Side Effects: If problematic cut increases back by 5 mg for 1 week and then add the extra 5 mg to dose. Discontinuation: Taper gradually over several months at low stress times Initiating and Continuing Fluoxetine Treatment * Start low and go slow Begin at 10 mg daily (if significant anxiety symptoms are present start with 5 mg) Continue 10 mg for one to two weeks then increase to 20 mg Continue 20 mg for a minimum of 8 weeks If side effects are a problem with the increase to 20 mg – decrease the dose to 15 mg daily for 1 week and then increase to 20 mg. If substantial side effects occur again continue the dose at 15 mg for a minimum of 8 weeks. * The PST based supportive rapport model should be used at every visit as a framework within which you can structure your interaction with your teenage patient.

Short Kutcher Chehil Side Effects Scale (sCKS) for SSRIs
Item None Mild Moderate Severe Headache Irritability/Anger Restlessness Diarrhea/Stomach upset Tiredness Sexual Problems Suicidal Thoughts Self Harm Attempt Yes: No: If yes, describe: Was this a suicide attempt (attempt to die)? Yes: No: Other problems 1. 2. Short Kutcher Chehil Side Effects Scale (sCKS) Clinicians who would like to use the short Chehil Kutcher Side Effects Scale in their individuals or group practice may do so without obtaining written permission from the authors. The short Chehil Kutcher Side Effects Scale may not be used for any other purpose (including publication) without expressed written consent of the authors.

Side Effects of SSRI’s Three important side effects to look for when initiating treatment with SSRI’s are… Hypomania Suicidal ideation Suicidal behaviors Side Effects of SSRI’s Hypomania Suicidal ideation or behaviors Monitoring side effects can be part of the role of the family and the school counsellors.

Hypomania Rare side effect: Decreased sleep Increase in activity
Idiosyncratic/inappropriate Increase in motor behavior (including restlessness), verbal productivity and social intrusiveness Discontinue medication. Urgently refer to mental health services. Family history of bipolar disorder. ID stockxchng Hypomania One rare side effect of medication treatment is the induction of hypomania. This presents symptomatically as: 1) Decreased need for sleep – subjective feeling that sleep is not needed 2) Increase in goal directed activity (may be idiosyncratic or inappropriate) 3) Increase in motor behaviour (including restlessness), verbal productivity, and social intrusiveness If hypomania is suspected the medication should be discontinued and urgent mental health referral initiated. Remember that a family history of bipolar disorder increases the risk for hypomania.

Suicide Ideation or Behaviors Health Canada Warning
May onset/exacerbate once medication is started but overall a substantial decrease: Stop medication immediately due to safety risk Most common in first several months of medication Suicidal ideation or Behaviors (Health Canada Warning) Suicidal thoughts or behaviours with onset or exacerbation once started on medication can be a side effect and requires stopping the medication due to the safety risk of this side effect. This side effect is most common in the first several months of initiating medication. ID stockxchng

Monitoring Treatment of Adolescent Major Depressive Disorder
Tool Base-line Day 1 Day 5 Wk 1 2 3 4 6 7 8 KADS x TeFA sCKS Monitoring Treatment of MDD Outcomes and side effects should be monitored regularly during treatment*. The following chart is suggested as a guideline. For treatment outcome evaluation use the KADS and the TeFA. For side effects assessment use the Short Chehil-Kutcher Side Effects Scale (sCKS) as illustrated on the next page. * The PST based supportive rapport model should be used at every visit as a framework within which you can structure your interaction with your teenage patient.

Monitoring Treatment of Anxiety Disorders
Tool Base-line Day 1 Day 5 Wk 1 2 3 4 6 7 8 SCARED x TeFA sCKS Monitoring Treatment of Anxiety Outcomes and side effects should be monitored regularly during treatment*. The following chart is suggested as a guideline. For treatment outcome evaluation use the SCARED and the TeFA. For side effects assessment use the Short Chehil-Kutcher Side Effects Scale (sCKS) as illustrated on the next page. Children – SCARED & sCKS Teens – SCARED, TeFA, sCKS

8 Weeks* of Dosage Now what?
3 Possible Outcomes 3 Different Strategies ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!! I have finished 8 weeks at recommended dosage– now what? * There will be three possible outcomes – each with a different intervention strategy. ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!

OUTCOME 1 OUTCOME 2 OUTCOME 3 Strategy
Patient not better or only minimally improved SCARED > 25 and little or no functional improvement Patient moderately improved SCARED < 25. Some functional improvement. (50-60% as determined from the TeFA) Patient substantially improved. SCARED < 25 and major functional improvement. Strategy Increase medication gradually Refer to Specialty Child/Adolescent Mental Health Services Continue weekly monitoring and all other interventions until consultation occurs If medication is well tolerated, increase slightly Continue monitoring/interventions for wks Reassess If no substantial improvement Refer If medication or increase not well tolerated continue at current dosage with monitoring and intervention for 2 wks Refer. Continue current dosage Gradually decrease visits; every 2 wks for 2 mths and then monthly Educate patients/caregivers on need to continue medications And identifying relapse If first episode continue medications for mths. If discontinuing, choose a low stress period. Decrease gradually over 4-6 wks monitoring every 2 wks. “Well checks” every 3 mths If 2nd or further episode obtain mental health consultation on treatment duration Outcomes for Treatment of Anxiety in Adolescents Outcome 1 Patient not better or only minimally improved SCARED > 25 and little or no functional improvement Strategy Increase medication gradually (fluoxetine to 20 mg or sertraline to 100 mg) Refer to Specialty Child/Adolescent Mental Health Services Continue weekly monitoring and all other interventions until consultation occurs Outcome 2 Patient moderately improved. SCARED < 25. Some functional improvement If medication is well tolerated, increase slightly (fluoxetine to 20 mg daily or sertraline to 100 mg per day) and continue monitoring and interventions for two to four weeks then reassess. If no substantial improvement then refer. • If medication is not well tolerated or increase not tolerated continue at current dosage with monitoring and intervention for two more weeks then reassess. If no substantial improvement then refer for specialty mental health treatment. Outcome 3 Patient substantially improved. SCARED < 25 and major functional improvement. Continue medication at current dosage • Gradually decrease monitoring and interventions visits to once every two weeks for two months and then monthly thereafter • Educate patients/caregivers about need to continue medications and how to identify relapse if it occurs • If first episode continue medications for months before jointly deciding to discontinue. If discontinuing choose a suitable window (low stress period) and decrease gradually (over a period of four to six weeks) monitoring every two weeks. • Agree on “well checks” (for example, once every three months) and how to identify relapse if it occurs • If second or further episode obtain mental health consultation on treatment duration Medication doses used in specialty mental health services may occasionally exceed those usually found in primary care. Physicians monitoring youth who have been treated by specialists should discuss medication dose requirements prior to initiating dose changes.

Medical Adherence

Checking Adherence to Treatment
Predict non-compliance Openly recognize probability Missing one or more doses of medication No need to feel guilty Occasional misses… …a little change in fluoxetine (long half-life) …a difference in missing sertraline (shorter half life) Checking Adherence to Medication Treatment Determining medication adherence can be difficult. It may be useful to predict the likelihood of medication non-compliance in advance. Openly recognizing that it is probable that the patient may miss one or more doses of medications is not only consistent with reality, but it allows the patient to miss the occasional dose without guilt, and to return to medication use without seeking permission to do so. Pharmacologically, if this happens occasionally there will be little if any substantive change in fluoxetine serum levels due to the long half-life of fluoxetine and its major metabolite (5 to 7 days). There can be a difference noticed in missing a dosage of sertaline as this medication has a shorter half life (just over 24 hours). Michal Marcol freedigitalphotos.net

Assessing Treatment Adherence 3 Methods
Enquire about medication use from child. Enquire about medication use from parent. Pill counts are sometimes useful. Assessing Treatment Adherence: 3 Methods There are three methods that can be used to monitor and assess treatment adherence. 1) Enquire about medication use from the child and parent. Using such prompts as: “How have things been going with taking the medicine?” or “As we talked before, it is not uncommon to forget to take your medicine sometimes. How many times since we last talked do you think you may have not taken your medicine?” It is important not to admonish the child/parent who self-identifies occasional medication non-adherence. When do they take the medication? Simply acknowledge the difficulty in remembering and ask if there is anything you can help with to improve their remembering. If the compliance with medications is poor it is important to address the issue openly, trying to understand what the reasons for the adherence difficulties may be. Once these have been identified they can be collaboratively addressed. 2) Enquire about medication use from the parents. Children should have parents dispense the medication. However, dispensing is not the same as taking. So even if the parents are dispensing the medication it is important to ask the child about medication use as described in method one above. Pill swallowing is sometimes difficult for children and causes distress with taking medication. Changing to liquid form (fluoxetine) or opening capsule (sertraline) can be helpful in improving compliance. 3) A pill count may sometimes be useful. Simply ask the child or parent to bring the pill bottle to each appointment. It is important to ask the child and parent about medication use as described in method one above and to check in about medication compliance in different settings if the child is moving between homes.

If relapse occurs… Evaluate the following: Compliance with treatment.
Medical illness. Onset of stressors that challenge patient. Onset of substance abuse. Alternative diagnostic possibility. Depression, anxiety disorder, bipolar disorder. Refer to mental health specialist if relapse occurs despite adequate ongoing treatment. If relapse occurs… If a patient relapses while on an adequate treatment regime evaluate the following: 1. Compliance with treatment 2. Medical illness 3. Onset of recent stressors that challenge the patient’s ability to adapt 4. Onset of substance abuse 5. Emergence of an alternative diagnostic possibility (such as: anxiety disorder, depression, bipolar disorder) Referral to a mental health specialist is indicated if relapse occurs despite adequate ongoing treatment.

Action Planning Fast Facts: Adolescent Depression
Adolescence = puberty to mid-twenties Affects approx. 6-8% of adolescents Most experience 1st episode between yrs old Youth onset usually = chronic condition Substantial morbidity Poor economic/vocational/interpersonal/health outcomes Increased mortality Suicide Other long term chronic illness: diabetes, heart disease, etc. Early identification & early effective treatment Decreases short-term morbidity Improves long-term outcomes Decreased mortality

Measures Aim Change Ideas

Changes to try… Identification and screening of children and youth.
Creation of a registry. Treatment processes. Team-based care - GP’s, Schools, other care providers. Linking with community programs and supports.

Action period planning – team activity
With your community team (e.g. GP, MOA, School Counselor, Mental Health Clinicians…), discuss what changes you will test in the action period. Fill out the action planning form. Write the PLAN for your first Plan, Do, Study, Act cycle. Discuss potential tests of change with your team Based on what you have heard today, what would you like to try next or like to try that you had not thought of before? Begin planning what these tests will look like What will you do when you get back to your community? Who will be involved? When will you start?

When in doubt – Ask the Experts!
Diagnosis of ADHD in Childhood using the SNAP-IV The SNAP-IV Teacher and Parent 18-item Rating Scale is a norm-referenced checklist that is designed to determine the presence of ADHD symptoms. The SNAP-IV can be used by any clinician assessing a young person for ADHD. This checklist can also be completed by either a parent or other caregiver or an educator for use by a healthcare provider in performing an assessment. One method of evaluating the SNAP-IV is to look at subscale scores. Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (e.g., Inattention) and dividing by the number of items in the subset (e.g., 9). The score for any subset is expressed as the Average Rating Per Item. The 5% cutoff scores for teachers and parents are provided. Compare the Average Rating Per Item score to the cut-off score to determine if the score falls within the top 5%. Scores in the top 5% are considered significantly different from “usual”. To meet DSM-IV criteria for ADHD, there must be at least 6 responses of "Quite a Bit" or "Very Much" (scored 2 or 3) to either the 9 inattentive items (1-9) or 9 hyperactive-impulsive items (10-18), or both on the SNAP-IV 18 item Rating Scale.

Sustaining your goals It’s never too early to consider how you are going to sustain your improvements. Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’. The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts. As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made. Some strategies for holding the gains once initial improvements have been made (tested and implemented): 1. To work towards sustaining a change long term patients, staff and providers need to be clear what the benefits are in terms of patient care, workplace satisfaction, and personal practice. Using measurement to show the improvements will help to support the change. When each stakeholder can explain ‘what’s in it for me’ the change is more likely to sustain. 2. The permanence of the change should not depend on specific people, but should become embedded in the work processes. One of the ways to do this is to establish and document standard processes, so that even if there are staff changes everyone will know what the new process is and be able to follow it. Additionally, a plan for training new employees will help to ensure that the new responsibilities and new processes are understood and carried out correctly, and ensues continuity in practice over time. 3. Data collection continues so that the practice has information about whether the gains are being maintained. It may be that the data collection schedule can be reduced, with data collection occurring less frequently or with a smaller sample. The objective here is to monitor the new system, and guide improvements as they are tested and implemented. 4. One suggestion for embedding the change and making it permanent is to review job descriptions so that new personnel will know immediately what is involved in their responsibilities. Additionally, make sure that any documentations of policies and procedures reflect any change in process. 5. It is important to celebrate when an achievement has been reached, but also important to celebrate when that achievement has been sustained for a period of time. Keep focus and energy up by celebrating with your team your continued best practice and reminding yourselves of the good work you have done.

Next Learning Session Date
Please make a note of the date of the next learning session – evening session, same format to be expected. Thanks to the physician facilitators for their leadership in this module. Again, we at PSP are here to support you and coach you each step of the way.

Practice Support Program
For more information Practice Support Program West Broadway Vancouver, BC V6J 5A4 Tel:

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