The role of the pediatrician in the mental health of children

1. The role of the pediatrician in the mental health of children

3. Overview • Of every 12 babies born today 1 will spend a portion of their life hospitalized for mental illness • 1/3 of the nation’s health bill is spent on mental illness • In any given year only 20% of children with mental disorders are identified and receive mental health services • Children with unidentified mental illness end up in jail and prison with 65% of boys and 75% of girls in juvenile detention having at least one mental illness • Effectively no chance to meet the need with Psychiatrists

4. Mental health definition • Mental Health – The U.S. Surgeon General, in 2001, defined mental health as the successful performance of mental function resulting in productive activities, fulfilling relationships with other people, and the ability to adapt, change, and to cope with adversity. • Mental illness – loss of these occurs • Can be viewed as a continuum • Virtually every study shows untreated mental illness decreases school and job performance

5. Successful Management Requires targeted and specific: • Prevention • Diagnosis • Treatment

6. Prevention • Start early: sleeping, eating, pooping • Self calming • Teach delayed gratification • Acceptance that things will not always go “my way” • Tolerance • Free play is a foundational cornerstone • Exercise • Keeping marriages healthy

8. Major screening areas in early childhood • Maternal depression • Parental mental health • Speech delays • Autism

9. Major screening areas in later childhood • Psychosocial stressors in family • Depression • Anxiety • ADHD • Screen marriage stability • Expect problems in divorce

10. Screening Tools • Informal Screening • Takes place at all well child visits • The younger the child the more general the question • Engage the child directly, early • Identified vulnerabilities need follow-up • Formal screening • Many, many screening tools available • M-CHAT • PHQ-9 • GAPS Questionnaire

11. Diagnosis • Diagnose with standardized assessments • Utilize psychologists for diagnosis • Include educators and other professionals in assessments

12. Treatment • Ideally needs multidisciplinary approach • Everyone with responsibilities to the child should be aware • Medical home model • Embedded social worker and psychologist

13. Components of a Medical Home • A partnership between the family and the child’s/youth’s primary health care professional • Relationships based on mutual trust and respect • Connections to supports and services to meet the non-medical and medical needs of the child/youth and their family • Respect for a family’s cultural and religious beliefs • After hours and weekend access to medical consultation • Families who feel supported in caring for their child • Primary health care professionals coordinating care with a team of other care providers • Source: American Academy of Pediatrics - The National Center of Medical Home Initiatives. “General Medical Home Info.” available at: http://www.medicalhomeinfo.org/health/general.html; accessed January 8, 2009.

14. Treatments to Coordinate • Parenting support and help • Deal with 1 room fires before they spread • Psychology • Directed and communicated interventions • Medications and follow up

15. Specific Conditions in a Pediatrician’s Scope • Child development • Some autism • Depression • Anxiety • ADHD • Behavior and psychosocial issues

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17. Sleep • Historically sleep issues have been thought of as a secondary effect of mental illness or coexisting with mental illness • New research points to sleep deprivation being a direct cause of mental illness

18. Irregular Bedtimes Associated with Increased Behavioral Problem sin ChildrenBy Joe Elia Children with irregular weekday bedtimes have more parent- and teacher-rated behavioral problems than those with regular bedtimes, a Pediatrics study finds. Some 10,000 U.K. children had their bedtimes reported by their mothers at ages 3, 5, and 7. At age 7, mothers and teachers assessed the children's behavior. Children with irregular bedtimes had higher rates of behavioral problems than those with regular bedtimes. There was a dose-response pattern, with irregular bedtimes at all three age assessments having the greatest effect on behavioral scores. Shifting to regular bedtimes was associated with improved behavior. Accordingly, the researchers point to "potential opportunities for interventions," noting that "screening for disruptions to bedtime schedules could be built into routine primary health care consultations.“ Physician's First Watch David G. Fairchild, MD, MPH, Editor-in-Chief, October 15, 2013

19. Sleep Strategies • Start good sleep habits in infancy • Discuss sleep at every well child care visit and stress importance • Consistent bedtime • Limited screen time before bed • Avoid caffeine

20. Sleep Induction • Defined as trouble falling asleep • Most common sleep problem in children • Helps to have a scheduled bedtime at every age • Melatonin, clonidine, most commonly used induction medications by pediatricians • Benadryl works but for short time use only

21. Sleep Maintenance • Defined as maintaining sleep through the night • Commonly associated with autism • More difficult to deal with than induction • Trazodone is our primary medication

22. Sleep Summary • Don’t underestimate the power of sleep • Sleep needs increase rather than decrease in teenage years • The law is the law – demand a scheduled bedtime • The electronics fight is always worth it

23. conclusion • How can we improve our care as part of a medical home model now? • How can communication between schools and medical professionals be enhanced? • Where do social services fit in?