Mental Health Learning Collaborative Learning Session April 10 2015 Speakers Bhavin Dave MD Childrens National Health System Katherine Hobbs Knutson MD MPH Childrens National Health ID: 753647
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Slide1
Managing Behavioral Problems and Substance Use
Mental Health Learning Collaborative Learning Session
April 10, 2015
Speakers
:
Bhavin Dave, MD, Children’s National Health System
Katherine Hobbs Knutson, MD, MPH Children’s
National Health
System
Nicole
Martino,
LICSW, DC Department of Behavioral HealthSlide2
Accreditation
Accreditation
The George Washington University School of Medicine and Health Sciences is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The George Washington University School of Medicine and Health Sciences designates this live activity for a maximum of 1.0
AMA PRA Category 1 Credit(s)™.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Instructions
for Obtaining Credit
At the end of this webinar, you will receive an email for completing the online course evaluation. Your certificate of credit will be available immediately after you complete the evaluation.Slide3
Disclosure
In
accordance with the Accreditation Council for Continuing Medical Education's Standards for Commercial Support,
The
George Washington University Office of Continuing Education in the Health Professions (CEHP) requires that all individuals involved in the development and presentation of CME activity content disclose any relevant financial relationships with
commercial interest(s). CEHP identifies and resolves all conflicts of interest prior to an individual’s participation in an educational activity.The following faculty, planners, and staff report that they have no relevant financial relationships with commercial interest(s):Bhavin Dave (Speaker)Katherine Hobbs Knutson (Speaker)Nicole Martino (Speaker)Mark Weissman, MD (Course Director)Tamara John, MPH (Staff Planner)Leticia Hall-Salam (Staff)
Commercial Support
:
This activity received no support from a commercial interest.Slide4
General Information
Release Date:
March 25,
2014
Termination Date: March 25, 2014Hardware/Software RequirementsPCMicrosoft Windows 2000 SE or above.Internet Explorer (v5.5 or greater), or FirefoxFlash Player Plug-in (9.0 or later) Check your version here.Sound Card & Speakers800 x 600 Minimum Monitor Resolution (1024 x 768 Recommended)Adobe Acrobat Reader*MACMAC OS 10.2.8Safari or FirefoxFlash Player Plug-in (9.0 or later) Check your version here.Sound Card & Speakers
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Adobe Acrobat Reader*
Internet Explorer is not supported on the Macintosh.* Required to view printable (PDF) version of the lesson.
Contact Information
Tamara John
Ph
: (202)476-5781
Em
:
tjohn@childrensnational.org
Policy on Privacy & Confidentiality
http://www.gwu.edu/privacy-policy
Copyright
http://www.gwu.edu/copyrightSlide5
Managing Behavior Problems in Youth
5
Bhavin Dave, MD
Assistant Professor-Department of Psychiatry and Behavioral Sciences
Associate Director-Infant & Toddler Mental Health Program
Children’s National Health System Slide6
AssessEvaluate for any mental health diagnosesRule out any medical issuesAssess for any psychosocial stressors
At home?
At school?Slide7
Managing BehaviorsTreat underlying psychiatric disordersTreat any comorbid medical issues
Address any psychosocial stressors
Identify target behaviorsSlide8
Managing BehaviorsList target behaviors Develop behavior intervention planRecruit support services to reinforce behavior planSlide9
Identify Target BehaviorsTarget behaviors may differ depending on age rangeList behaviors most
least impactful
Type of intervention may depend on type and scope of behavior
Low acuity (oppositional, defiant, limit testing, noncompliant, mild aggression)
Moderate acuity (moderate aggression, bullying, destruction of property, truancy, running away)
High acuity (urgent/emergent behavior, i.e. threats of harm to self or others)Slide10
Basic PrinciplesPick and choose battles!Some behaviors may require effective ignoring
Be consistent, persistent (as best as possible)
Behaviors may get worse before they get better
Identify any parent/caregiver behaviors that inadvertently reinforce negative behavior
Praise/positive reinforcement is more effective than consequence/punishment
Involve the child as much as possibleSlide11
Low Acuity BehaviorsDevelop behavior intervention planIdentify and teach rules
Determine consequences
Determine praise/rewards
Who is involved?
Parents
SchoolTherapist (behavior, play, individual, family)Slide12
Moderate AcuityDevelop behavior intervention planPrevention—teaching coping skills
Safe de-escalation techniques
Anti-bullying interventions in school
Create non-aggressive environment
External source of consequences (ie PINS program)
MST (Multi-systemic therapy)Who is involved?ParentsSchoolTherapist (in-home, behavioral, CBI worker, individual, family)DJSSlide13
High Acuity BehaviorsDevelop intervention planMaintain safety
Crisis evaluation
Safe transport to appropriate placement
Who is involved?
Crisis intervention services (911,
ChAMPS: 202-481-1440)Inpatient unit DJS Slide14
Resources for Parents"The Kazdin Method for Parenting the Defiant Child."—Allen E. Kazdin, PhD
“Your Defiant Child”—Russell Barkley, PhD
“SOS Help for Parents”—Lynn Clark, PhD
“1-2-3, Magic”—Dr. Thomas Phelan “The Whole Brain Child”—Daniel Segal “No More Meltdowns”—Jed BakerSlide15
Substance Abuse Screening & Brief I
ntervention
15
Katherine Hobbs Knutson, MD, MPHSlide16
Substance abuse screening
For adolescents, in addition to the SDQ screening (and suicide screening), DBH and the DC Collaborative recommend practices to additionally screen for substance abuse with the CRAFFT tool.Slide17
CRAFFT screening tool, Children’s Hospital Boston, 2009.Slide18
CRAFFT screening tool, Children’s Hospital Boston, 2009.Slide19
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide20
Available at:
http://www.integration.samhsa.gov/clinical-practice/sbirt/Guide_for_Youth_Screening_and_Brief_Intervention.pdfSlide21
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide22
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide23
Negative CRAFFT screenNegative CRAFFT screen: provide positive reinforcement for abstinence, consider exploring the choice for abstinence with the patient.Slide24
Positive CRAFFT screenSlide25
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide26
CRAFFT screening tool, Children’s Hospital Boston, 2009.Slide27
Positive CRAFFT screen“No” to all questions in part A + “Yes” to CAR questionDescribe dangers of riding with a person who has been using alcohol/drugs
Consider “Contract for Life”Slide28
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide29
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide30
CRAFFT screening tool, Children’s Hospital Boston, 2009.Slide31
Positive CRAFFT screen“Yes” to one question in part ACounsel patient on negative health effects of drug and alcohol use.
Try to identify a negative aspect of drug/alcohol use that the patient has recognized independently.
Agree to stop using drugs/alcohol.Slide32
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide33
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdfSlide34
Positive CRAFFT screen“Yes” to >2 questionsSlide35
Positive CRAFFT screen“Yes” to >2 questions
Assess type of
drug(s
) used, quantity and frequencySlide36
Positive CRAFFT screen“Yes” to >2 questions
Assess type of
drug(s
) used, quantity and frequency
Assess for substance use disorder diagnosisSlide37
DSM 5 criteria for substance use disorder
The new DSM describes a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
1. The substance is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
4. Craving, or a strong desire or urge to use the substance.5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.8. Recurrent use of the substance in situations in which it is physically hazardous.9. Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.10. Tolerance, as defined by either of the following: -A need for markedly increased amounts of the substance to achieve intoxication or desired effect. -A markedly diminished effect with continued use of the same amount of the substance.11. Withdrawal, as manifested by either of the following: -The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance). -The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.mild substance use disorder is suggested by the presence of 2-3 symptoms, moderate by 4-5 symptoms, and severe by 6 or more symptomsSlide38
Positive CRAFFT screen“Yes” to >2 questions
Assess type of
drug(s
) used, quantity and frequency
Assess for substance use disorder diagnosis
Assess patient’s willingness and perceived barriers to decreasing useSlide39
Positive CRAFFT screenOptions for intervention:Develop a plan to decrease use and follow up in 1 month within primary care to assess progress
For more serious substance abuse conditions, refer for specialty treatment
For safety concerns, refer to the EDSlide40
Positive CRAFFT screen
Motivational interviewingSlide41
CRAFFT screen
Part A, response
Part B, response
Risk level
Intervention
“No” to all questions“No” to all questionsLowPraise good choices.“No” to all 3 questions“Yes” to CAR questionElevatedProvide “Contract for Life.”“Yes” to 1 question“No” to all questionsElevatedRecommend abstinence.“Yes” to >1 questions
“Yes”
to
>1 questionsHighAssess for substance use disorder, motivational interviewing, refer for treatment.Slide42
Presentation Topic:
Substance Use and Co-Occurring Treatment and Services
Presentation Purpose:
Provide
P
ediatric Primary Care Physicians information regarding programs and resources for youth with substance use issues in D.C.
Youth Treatment Coordinator
Nicole Martino, LICSW
April 10th, 2015
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Behavioral Health
DC Department of Behavioral HealthSlide43
Programs Four ASTEP (Adolescent Substance Treatment Expansion Program) Providers:
Hillcrest Children and Family Center
Latin American Youth Center
Riverside Treatment Center
Federal City Recovery
DC Department of Behavioral HealthSlide44
Screening and Assessment Family of GAIN Instruments: An evidence based tool utilized to screen and assess for substance use and co-occurring mental health disorders
GAIN SS- Screening
GAIN I- Comprehensive Assessment
GAIN M-90- Follow up (assesses changes)
DC Department of Behavioral HealthSlide45
Treatment Adolescent Substance Use Treatment: All four ASTEP Providers are able to provide outpatient and intensive outpatient substance use treatment to include the following:
Group Therapy
Case Management
Clinical Care Coordination
Individual Therapy
DC Department of Behavioral HealthSlide46
Co-Occurring Treatment: All ASTEP Providers are trained to assess for co-occurring disorders utilizing the GAIN Tools
Three of the four ASTEP Providers are trained in the Evidence Based Treatment Model: ACRA (Adolescent Community Reinforcement Approach)
Hillcrest Children and Family Center
Latin American Youth Center
Riverside Treatment Center
Treatment Continued…
DC Department of Behavioral HealthSlide47
Access to Services Adolescents and their families can access services by contacting the Access Helpline for enrollment or by contacting any of the four ASTEP Providers directly to make an appointment.
DC Department of Behavioral HealthSlide48
Contacts
Access Helpline: (888) 7WE-HELP/(888) 793-4357
Four ASTEP Providers
Hillcrest Children and Family Center: (202) 232-6100
Latin American Youth Center: (202) 319-2265
Riverside Treatment Center: (202) 889-3182Federal City Recovery: (202) 548-8460Department of Behavioral Health- Assessment and Referral Center: (202) 727-8473
DC Department of Behavioral HealthSlide49
Questions?Bhavin Dave, MD: bdave@childrensnational.org
Katherine
Hobbs Knutson, MD
MPH:
khknutso@childrensnational.org
Nicole Martino, LICSW: nicole.martino@dc.gov 49