Fall 2009 ★ Issue Fourteen
A Publication Dedicated to the Young Minds of America from the NAMI Child & Adolescent Action Center
Integrating Mental Health and Primary Care
The Medical Home: A Model for 21st Century Health Care Improving ADHD Care with Community-based Interventions in Primary Care T h e Yo u t h V o i c e ★ S t a t e a n d A f f i l i a t e N e w s ★ Fa m i l y V o i c e
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POLICY ALERTS Capitol Hill and State House Watch
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Producing Positive Outcomes by Integrating Mental Health in Primary Care
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The Medical Home: A Model for 21st Century Health Care
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Improving ADHD Care with Community-based Interventions in Primary Care
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FAMILY VOICE YOUTH VOICE ASK THE DOCTOR STATE NEWS AFFILIATE NEWS
NAMI Beginnings is published quarterly by NAMI, 3803 N. Fairfax Dr., Suite 100, Arlington, VA 22203-1701 Ph: (703) 524-7600 Fax: (703) 524-9094 Michael Fitzpatrick, Executive Director Darcy E. Gruttadaro, J.D., Editor-in-Chief Dana C. Markey, Managing Editor Courtney Reyers, Copy Editor Joe Barsin, Art Director Guest Contributors: Jeff N. Epstein, Ph.D. Karen Hacker, M.D., M.P.H. Joshua M. Langberg, Ph.D. Marie Y. Mann, M.D., M.P.H. Ann Nelson Brenda Reiss-Brennan, M.S., A.P.R.N. Kathryn Scheele Stephanie Souza, M.B.A Sherri Wittwer, M.P.A. Staff Contributors: Darcy Gruttadaro and Dana Markey The National Alliance on Mental Illness (NAMI) is the nation’s largest grassroots mental health organization dedicated to improving the lives of individuals and families affected by mental illness. NAMI has over 1,100 affiliates in communities across the country that engage in advocacy, research, support, and education. Members of NAMI are families, friends, and people living with mental illnesses such as major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder.
NAMI Web site: www.nami.org NAMI HelpLine: 1 (800) 950-6264 © 2009 by National Alliance on Mental Illness. All rights reserved
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A L E R T S
Capitol Hill and State House Watch by Darcy Gruttadaro, J.D., director, NAMI Child and Adolescent Action Center
Health Care Reform and Budget Crises Federal Health Care Reform. As federal legislators tackle health care reform, it is timely to focus on the need to integrate mental health and primary care, especially for children. It is in the early years of life that most children and youth regularly visit physician offices. This is an important time to evaluate the health and well-being of children, including an evaluation of every child’s mental health. Children should be examined from the tops of their heads to the tips of their toes. When mental health concerns arise or are discovered, those children should be examined more closely and provided with the most appropriate and effective services and supports. This approach is necessary to keep young lives on track—and is consistent with the approach taken for other health concerns and conditions. The early identification of mental health conditions is essential to the health and well-being of children, along with links to effective services and supports. Referrals to child mental health specialists is not always easy given the workforce shortage of child psychiatrists and other child-serving mental health professionals. It is these and similar concerns that led NAMI and other child advocacy organizations to call on the leadership of the U.S. Senate to include the following five key principles in the final Senate health care reform bill: 1. Affordable health care coverage for all children, youth and young adults up to age 26 that covers prevention, early identification and intervention with effective treatment, services and supports for both mental health and substance use disorders. 2. Health plans that do not impose restrictions on pre-existing conditions,
do not terminate coverage when individuals are sick and require coverage for mental health assessment and treatment on par with that provided for general health care. 3. A health care system that requires plans to provide culturally and linguistically appropriate services to address racial and ethnic disparities as well as disability-based health disparities. 4. Incentives for the integration and coordination of primary care and specialty mental health services. 5. Incentives to produce a competent and accessible mental health workforce, prioritizing the need to address child mental health workforce shortages. We strongly encourage families to weigh in on the health care reform debate by contacting their Congressional members and sharing the most pressing issues in their communities when it comes to children’s health care coverage. State and Local Budget Crises. These are unique and extraordinary times. Forty-eight states face extreme budget shortfalls, nearly all into the billions of dollars. Unemployment is at an all-time high. Projections indicate that it will take several years after the recession ends for states to recover from the financial crisis. Governors and local community leaders will be forced to decide where to cut budgets. The mental health and social service systems too often are the first on the chopping block. It is our job to let state and local leaders know that mental health and social service budgets are off limits. In light of the budget crises, NAMI is developing a new section on our Web site that includes tools and continued on page 3
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Producing Positive Outcomes by Integrating Mental Health in Primary Care by Brenda Reiss-Brennan, M.S., A.P.R.N, mental health integration director, Intermountain Healthcare
he health care crisis in the U.S. health system today has exposed fundamental flaws in our ability as a society to promote health and well-being, as evidenced by increased costs, inadequate access, medical errors and marginalized quality. The uninsured, vulnerable and chronically ill suffer the heaviest cost burden—discrimination—and are most likely to go without needed care (Tu, 2009). Children, adolescents and their families are particularly vulnerable within the current health delivery system. Most children and adolescents make at least one primary care medical visit annually, with approximately one in four experiencing a clinically significant mental illness. Primary care providers (PCPs) are often the first resource for families and prescribe the majority of psychoactive medications to children in the United States, but their role in mental health service delivery remains ambiguous. Low recognition rates for early-onset mental illness are the rule in primary care and affected children often do not receive any mental health services. Access to mental health services and supports has become increasingly limited, particularly for children and families living in rural areas (Ravens-Sieberer, 2008). The public health importance of the primary care setting in the identification and management of
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Brenda Reiss-Brennan common pediatric mental illness has never been better recognized. Over the last 10 years, Intermountain Healthcare has developed a team-based approach for caring for these children, adolescents and their families, known as Mental Health Integration (MHI). The team includes a doctor and office staff who are connected with mental health professionals, community resources, care management and of course, the patient and the patient’s family. As part of the MHI program, primary care physicians and support staff,
mental health specialists and care managers receive standardized training to enhance their confidence and ability to identify and treat mental illness in primary care. This training is embedded in ongoing clinic operations and focuses on how to engage respectfully and sensitively with families and how to reduce the impact of stigma by treating mental health as a normal part of the health care experience. What does this mean for child and adolescent patients seen in the MHI clinics? This means, first and foremost, continued on page 4
continued from page 2 advocacy materials that can be used to block proposed budget cuts to mental health services and supports. Please take advantage of these resources so that together we can protect the limited resources that exist for our fragile mental health care system. Beginning in early December, visit our newly developed state advocacy section on the NAMI Web site at www.nami.org/stateadvocacy. Updates to come … stay tuned! Fall 2009 | Issue 14 | Nami Beginnings | 3
F E A T U R E continued from page 3 that if a mental health related issue arises during a health visit, the primary care doctor will discuss it with them and their families. Mental health concerns are identified and managed using several assessment tools and resources. At the request of their doctor, patients and family members may complete a comprehensive mental health screening assessment, either on paper or online. Doctors use the assessment to screen for mental health conditions, evaluate the support system of the patient and family and ascertain their natural coping style and treatment preferences. The doctor reviews with the patient and family the health information and screening tools, family risk factors, severity of symptoms and possible diagnoses. The complexity of the mental health concerns are mutually assigned to a mild, moderate or high level of complexity and then matched to the appropriate level of team intervention and care management.
PHQ-9 is a patient health questionnaire used to help diagnose depression. GS scores are global severity scores used to measure overall psychological distress. active members of the team. Each member has a defined complimentary role on the team that requires a process of co-production and mutual aid in reaching positive outcomes. The co-production approach assumes that people who use services have expertise and assets which are essential to creating effective services and good practice (Needham, 2009). This relational, team
Primary care physicians need families and individuals living with mental illness to help them lead this effort in making programs like MHI available for all. Some children and adolescents may have anxiety, attention deficit/hyperactivity disorder (ADHD), depression or act out at school. Some may have problems with behavior or substance use that can lead them to juvenile court. Integrating mental health care into the primary care setting helps the doctor who does not specialize in mental health appropriately address these kinds of issues or know when to refer to the on-site mental health team. Since Intermountain Healthcare has mental health experts working in a team approach at its clinics, both preventive care and consultation are readily available. This is especially important because families in a crisis or who need help may have difficulty being sent to another unfamiliar location. The team approach includes having peer advocates, patients and families as 4 | Nami Beginnings | Issue 14 | Fall 2009
approach assists patients and families in obtaining the education and services they need to manage mental health and other chronic conditions while engaging them in self-management and peer support activities to promote recovery and wellness. Interventions that expand the relational family context of chronic disease are cost effective and enhance protective factors that can affect outcomes over time (Fisher et al., 2000). A partnership between Intermountain Healthcare and NAMI Utah promotes community-based support and engagement driven by families and individuals living with mental illness. Care managers tap into this advocacy resource to link patients and families with support groups and peer counseling that can help foster recovery.
The integration model provides access to a team-based approach in a familiar setting where parents and their children can seek answers for difficult concerns that may have long-range effects on the well-being of their families. Patients and doctors working together in MHI clinics report improved satisfaction and better quality outcomes, all at a lower cost to the health system (Reiss-Brennan, 2006). MHI is a successful approach to reducing stigma and improving the wellbeing and health of patients and their families with mental health conditions in their primary care health home. Primary care physicians need families and individuals living with mental illness to help them lead this effort in making programs like MHI available for all. To learn more about Intermountain Healthcare, visit their Web site at www.intermountainhealthcare.org. References Fisher, L. et al. (2000). Can addressing family relationships improve outcomes for chronic disease? Journal of Family Practice, 49, 561-566. Needham, C. (2009). Co-production: an emerging evidence base for adult social care transformation. Research Briefing: Social Care Institute for Excellence, March 1-22. Ravens-Sieberer, U. (2008). Mental Health of Children Adolescents in 12 European Countries-Results from the European KIDSCREEN Study. Clinical Psychology and Psychotherapy, 15, 154-163. Reiss-Brennan, B. (2006). Can mental health integration in a primary care setting improve quality and lower costs? Journal of Managed Care Pharmacy, March, 12 (2 Supplement), 14-20. Tu, H. (2009). Financial and health burdens of chronic conditions grow. Tracking Report: Health System Change, April, 24, 1-6.
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The Medical Home: A Model for 21st Century Health Care by Marie Y. Mann, M.D., M.P.H., medical officer, Child Health Bureau, Health Resources and Services Administration
he medical home is a model for 21st century health care, with a goal of addressing and integrating high quality health promotion, acute care and chronic disease management in a planned, coordinated, comprehensive, compassionate, culturally effective and patient/family-centered manner. It has been recognized as a model of care that not only benefits children and youth with special health care needs but all children, youth and adults— particularly those in “safety net settings.” The American Academy of Pediatrics (AAP) first coined the term “medical home” in 1967 to describe a central source of a child’s pediatric records. The concept evolved from a centralized medical record to an approach of providing health care that recognizes the needs of the total child and family in relation to health, education, family support and the social environment. What does that mean for a child and family? As promoted by the AAP, the medical home is built on a trusting, collaborative, working partnership between the child, family and primary care practitioner in cooperation with specialty care practitioners and the community network of medical and non-medical resources. With a central focus on the needs of the child, the medical home is an available and reliable source for comprehensive care where families are welcomed and recognized as the constant in a child’s life. Their cultural backgrounds are respected and they receive the assistance they need to be involved in their child’s care, including easily understandable information and interpreter services. The medical home team works to provide ongoing primary and preventive care. The team also facilitates access to and coordinates with a broad range of specialty, ancillary and
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related community services to provide comprehensive services for the child and family. This includes those that address mental health and developmental concerns. The medical home team assists with transitioning as a child moves along and within systems of services and from adolescent to adult health care. In March 2007, the AAP, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association
released Joint Principles of the PatientCentered Medical Home to describe an approach to providing comprehensive primary care for children, youth and adults. Adopting many characteristics of the AAP definition, the patientcentered medical home (PCMH) also emphasizes quality and safety as hallmarks of the medical home and recognizes the added value provided to patients who have a PCMH. The level of national collaboration among health professionals has raised the scope and
NAMI Basics Education Program The Fundamentals of Caring for You, Your Family and Your Child Living with Mental Illness NAMI Basics, an education program for parents and caregivers of children and adolescents living with mental illness, continues to expand across the country with outstanding results. It has been implemented successfully in more than 20 states and additional states have been selected to receive training on the program this fall, including Massachusettes, New York, Oklahoma, Virginia and Washington. NAMI Basics focuses on providing parents and caregivers with the information and support they need to make the best decisions possible for their children, families and themselves and to cope effectively with their situation. It has received overwhelmingly positive feedback from parents and caregivers who have participated in the course. NAMI Basics is taught by parents or other primary caregivers who
have lived experiences with their own children. It is free of charge and includes six different classes, two and a half hours each, that cover the following topics, among others: • the stages of emotional reactions of families to mental illness; • the biology of mental illness and getting an accurate diagnosis; • the latest research; • overview of treatment options; • the impact of a child’s mental illness on the rest of the family; • strategies to address challenging behaviors; • problem solving, listening, communication and coping skills; • overview of child-serving systems; and • advocacy. To learn more about NAMI Basics or to see if your NAMI state organization or local affiliate has the program available, visit the NAMI Basics Web site at www.nami.org/basics.
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www.pcpcc.net
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scale of medical home activities and discussions throughout the nation. Seen by many as a solution to a fragmented health system, the PCMH model is generating broad support among a wide and diverse range of health care stakeholders. These stakeholders share the following goals: • improving delivery of comprehensive primary care; • having better outcomes for patients; • establishing more efficient payment to health care practitioners; • increasing satisfaction; • maintaining better value; • increasing accountability; and • increasing transparency for purchasers and individuals living with mental illness. The Patient Centered Primary Care Collaborative (www.pcpcc.net), made up of national business groups, health care plans and organizations, other medical specialty societies and patient organizations, is helping to foster policies that support medical home implementation at the state and federal level. As of the end of 2008, more than 40 states have some form of legislation to support or mandate the medical home approach for care delivered to some or all of the states’ populations. Numerous pilot and demonstration projects are underway to test the value of the medical home, to examine the necessary financing mechanisms to sustain the medical home and to assess how best to implement it. It is anticipated that widespread implementation of the medical home approach will result in increased access to high quality health care for our nation’s youth and adults. The Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA/MCHB) supported the development of the National Center for Medical Home Implementation Web site (www.medicalhomeinfo.org), which is the premier resource for those working to improve the lives of children and youth, including those with special health care needs and their families. The Web site contains resources, state-specific links, information and tools and practical strategies on how
www.familyvoices.org/info/ncfpp/f2fhic.php to provide medical homes. Nearly all materials on the Web site are available free to download. Through its demonstration grant programs, HRSA/MCHB has also supported medical home activities in every state and territory to build the necessary state and community infrastructure needed to assure access to a medical home for every child. The Early Childhood Comprehensive Systems Grants in every state include medical homes as a key element. The State Implementation Grants for Improving Systems of Services for Children with Special Health Care Needs identify access to medical homes as a key component and grantees focus at least a portion of their project activities on promoting the medical home concept. In addition, HRSA/MCHB provides funding to Family-to-Family Health Information Centers (www.familyvoices. org/info/ncfpp/f2fhic.php) in the 50 states and Washington, D.C., to provide family-friendly information and training to families on accessing and financing health care services and supports for their children. The centers also provide referrals and support to connect families with family advocates and professionals in their communities. To learn more about the medical home, contact Marie Y. Mann at mmann@hrsa.gov.
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Improving ADHD Care with Community-based Interventions in Primary Care by Jeff N. Epstein, Ph.D., and Joshua M. Langberg, Ph.D., Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Center for ADHD
Background Attention-Deficit/Hyperactivity Disorder (ADHD) has a prevalence rate of 8.6 percent among children, which translates into approximately five million children in the United States who require ADHD-related mental health services (Froehlich et al., 2007). The mental health system and specialty mental health providers in the United States do not have the capacity to accommodate this number of children. As a result, the majority of children with ADHD receive diagnosis and treatment services from their primary care physicians. The American Academy of Pediatrics (AAP) recognizes the need for primary care physicians to assess and treat children with ADHD. In 2000 and 2001, the AAP issued consensus guidelines, which provide primary care physicians with a set of evidence-based recommendations for the assessment and treatment of children with ADHD (AAP, 2000; AAP 2001). The AAP assessment guidelines emphasize the importance of collecting parent and teacher standardized rating scales and using the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria as the basis for making an ADHD diagnosis. Treatment guidelines focus on providing systematic follow-up, including the collection of follow-up parent and teacher rating scales to quantitatively assess response to treatment. Despite promotional efforts and physician awareness, it is evident that the AAP recommendations are not being reliably implemented in the community.
The ADHD Collaborative Intervention Cincinnati Children’s Hospital Medical Center (CCHMC) developed an intervention termed the ADHD Collaborative Intervention, which is designed to promote adherence to the AAP practice guidelines among community providers. More than 200 primary care physicians in greater Cincinnati have been trained with the ADHD Collaborative Intervention. The ADHD Collaborative Intervention begins with two lectures devoted to teaching the recommendations provided by the AAP on ADHD. However, the ADHD Collaborative Intervention was developed based upon the realization that the didactic lectures alone are not sufficient for changing physicians’ behaviors (Langberg, Brinkman, Lichtenstein & Epstein, 2009). Implementing the AAP ADHD guidelines in a community practice is a complicated process that involves multiple steps and requires coordination of personnel on multiple levels. The ADHD Collaborative Intervention assists physicians with modifying their daily office policies, procedures and staff responsibilities in order to efficiently and effectively provide evidence-based care for children living with ADHD. Physicians are also provided with a variety of assessment tools (e.g., Vanderbilt ADHD Rating Scales) and are given instructions on administration and interpretation. After training, each practice keeps a log of elementary school-aged patients who are newly diagnosed with ADHD. The CCHMC research team conducts medical chart audits of each patient
listed on the log on a quarterly basis. Physicians are then sent a quarterly score card summarizing how they are doing in complying with the AAP guidelines. A physician at CCHMC with expertise in the diagnosis and treatment of ADHD in community settings is available to consult with practices on challenges they experience with implementation. Results Before receiving the intervention, rates of AAP recommended practice behaviors were low in the community. After completing the intervention, primary care providers showed substantial improvement in their use of AAP recommended practice behaviors during the assessment and treatment of children with ADHD. For example, use of standardized parent and teacher rating scales to formally assess and diagnose ADHD as required by the DSM-IV increased from 52 percent before the intervention to nearly 100 percent after the intervention. The use of standardized parent and teacher rating scales to consistently and thoroughly monitor medication response improved from a baseline of 9 percent to 40 percent. Significance This study demonstrates the effectiveness of a community-based intervention with primary care providers that promotes the adoption of the AAP guidelines for assessing and treating children living with ADHD. Since this intervention was implemented across a large and diverse sample of primary care providers and because the inter-
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F E A T U R E vention comprehensively addresses both assessment and treatment of children with ADHD, it appears particularly amenable to training large numbers of primary care providers to adhere to the AAP ADHD assessment and treatment recommendations. What Is Next? With funding from the National Institute of Mental Health, investigators at Cincinnati Children’s Hospital are currently working on ways to disseminate this intervention to other communities. Currently, pediatricians in Dayton, Ohio and Lexington and Louisville, Ky., are being trained to use this intervention through videoconference training and a Web portal that allows pediatricians to collect parent and teacher rating scales online. The Web portal scores rating scales in real time and provides pediatricians
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with reports as well as immediate warnings when side effects emerge or behavioral deterioration occurs. The Web portal also continually updates information regarding physician practice behavior, thereby allowing pediatricians to view how they are doing in relation to the AAP guidelines. As a way to encourage pediatricians to engage in this quality improvement intervention, the investigators have received approval as an official American Board of Pediatrics quality improvement activity, which is now a requirement for pediatricians wishing to renew their licenses. The investigators at CCHMC hope to effectively disseminate this intervention to practices across the country. For more information about the ADHD Collaborative Intervention, contact Joshua M. Langberg, Ph.D., at Joshua.Langberg@cchmc.org.
References American Academy of Pediatrics (2000). Clinical practice guideline: Diagnosis and evaluation of the child with Attention Deficit/Hyperactivity Disorder. Pediatrics, 105, 1158-1170. American Academy of Pediatrics (2001). Clinical practice guideline: Treatment of the school-aged child with Attention Deficit/ Hyperactivity Disorder. Pediatrics, 108, 10331044. Froehlich, T., Lanphear, B., Epstein, J., Barbaresi, W., Katusic, S. & Kahn, R. (2007). Prevalence and treatment of attention-deficit/ hyperactivity disorder in a national sample of U.S. children. Archives of Pediatrics and Adolescent Medicine, 161(9), 857-864. Langberg, J.M., Brinkman, B.B., Lichtenstein, P.K & Epstein, J.N. (2009). Interventions to promote the evidence-based care of children with ADHD in primary care settings. Expert Review of Neurotherapeutics, 9, 477-487.
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Navigating the Insurance Maze by Ann Nelson, parent and family research coordinator, NAMI Connecticut
y incredible daughter, Emily, is a compassionate, spontaneous and courageous 16-year-old girl with an inventory of mental health diagnoses longer than a weekly grocery list. During the course of a 12-year period, she was diagnosed with anxiety, attention-deficit/ hyperactivity disorder (ADHD), earlyonset bipolar disorder, oppositional defiant disorder (ODD), pervasive developmental disorder (PDD) and psychosis not otherwise specified (NOS). She has been on more than 22 different psychiatric medications, hospitalized three times (at the age of 8), educated in four different therapeutic schools (two of which were residential) and received numerous outpatient and home-based mental health services. The grief and heartbreak I have felt for my daughter has
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been excruciating. In addition to this visceral pain, I have been further exhausted by navigating the complexities and challenges of our mental health system. I have faced numerous obstacles in my relentless advocacy for quality mental health care for my daughter. One of the most burdensome struggles has been the arbitrary restrictions and limitations placed on her care by our health maintenance organization (HMO). Our HMO has frequently refused to authorize the necessary inpatient and outpatient psychiatric treatment for Emily, citing various reasons including the following: • the treatment is not medically necessary; • she does not meet the criteria for inpatient admission or ongoing hospital stay; • she has been admitted recently,
so we are allowing her only 48 hours of inpatient stay; • only the generic form of that medication is covered; • we do not cover community-based services; and • the reasonable and customary charge for that practitioner is $65, not $120. In my attempt to steer through and around these insurance barriers, I have found several state agencies that focus on individuals living with mental illness and their families to be islands of hope in this endless maze. These agencies have offered me and many other families support and a wealth of information on how to hold insurance companies accountable. I offer kudos to three specific state agencies that have been tireless warriors in ensuring that insurance companies are committed to meeting their contractual
F A M I L Y obligations to individuals living with mental illness and their families. The first agency is the Connecticut State Attorney General’s Office. Within this office is a specialized department, the Health Care Advocacy Unit, which provides advisory assistance to individuals living with mental illness and families who have been denied payment for health-related expenses involving managed care. Their efforts have resulted in multiple investigations into the insurance industry’s practices regarding access and coverage for mental health services for children. Press conferences have been held and legislation has been developed to protect the rights of children and adolescents living with mental illness and to ensure that Connecticut’s mental health parity laws are upheld. Connecticut also has a unique advocacy entity, the Office of the Health Care Advocate, which is dedicated to serving Connecticut’s health insurance consumers by resolving conflicts within insurance plans. This organization takes a multifaceted approach, including directing advocacy for individuals and families, educating the insured on their rights and the appeals process, providing coordination between various state and private health agencies and proposing legislation to remove unnecessary barriers to health care access under managed care plans. A third state agency that has partnered with families is the State Office of the Child Advocate. The agency’s mission is to oversee the protection and care of children and to advocate for their well-being. The Child Advocate often collaborates with the Attorney General’s Office to collectively promote fair and responsible treatment practices for all children in the state. I was privileged to work with both the Child Advocate and the Attorney General’s Office in an investigation into private insurance companies’ inadequate availability of child psychiatrists in their networks. This investigation was published in A Report of the Attorney General and Child Advocate’s Investigation of Mental Health Care Available to Children in Connecticut. In addition to these agencies, I have been fortunate to be surrounded by a
team of state and federal legislators who have been champions for children and adolescents living with mental illness. Sen. Christopher Dodd (D-Conn.), a senior democrat on the Senate Committee on Health, Education, Labor and Pensions (HELP) and chairman of its Subcommittee on
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agencies and organizations as well as legislators committed to the lives of children and adolescents living with mental illness. I encourage you to continue to persevere in obtaining the necessary mental health care for yourself and your family. The first step in this journey is to partner with your
The agency’s mission is to oversee the protection and care of children and to advocate for their well-being. Children and Families, has been a voracious advocate for individuals living with mental illness. He has been a long-standing supporter of federal mental health parity legislation. I had the joy of working with him and celebrating with him in 2004 with the passing of The Garrett Lee Smith Memorial Act, federal suicide prevention legislation. You may not live in Connecticut, but all states have patient advocacy
NAMI state organization or your local NAMI affiliate. It is in the company of others like ourselves that we can grow amidst adversity. As Winston Churchill articulated, “a pessimist sees difficulty in every opportunity; an optimist sees opportunity in every difficulty.” May we be relentless optimists with the flag of recovery forever waving. To learn more about navigating the insurance maze, contact Ann Nelson at familyresearch@namict.org.
Telehealth for School-based Mental Health he University of Texas Medical Branch (UTMB), the Robert Wood Johnson Foundation, the Galveston Independent School District and Galveston’s philanthropic community have established and successfully implemented a collaborative Telehealth for School-based Mental Health program to meet the mental health treatment needs of adolescents in area secondary schools. Telehealth for School-based Mental Health aims to close the gap in access to mental health services for adolescents in the Galveston community by providing families and doctors face-to-face communication via state-of-the-art video conferencing equipment. The program links four school-based Teen Health Clinics with mental health providers on the UTMB campus and elsewhere. It allows for timely care to be provided to those who otherwise may not have access to care for a variety of reasons. The program also incorporates an
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www.utmb.edu/hpla/telehealth.asp electronic medical system to guarantee coordination of care between providers and school sites. The program has received recognition from the Agency for Healthcare Research and Quality as an innovative, evidence-based program. The program is currently in its third year and has produced promising results in improving access to mental health services for adolescents and their families and improving outcomes for adolescents living with mental illness. To learn more about the Telehealth for School-based Mental Health program, visit www.utmb.edu/hpla/ telehealth.asp.
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Kidshops: Learning I Am Not Alone and How to Support Siblings and Peers by Kathryn Scheele, sibling, Age 13 y name is Kat and I go to a program called Kidshops. NAMI Minnesota developed the Kidshops program for children with a sibling or parent living with a mental illness. It is free for youth ages 7-17 and is facilitated by trained adults who either have a sibling or a parent living with a mental illness. Basically, it is a program for kids like me who have a brother, sister or parent living with a mental illness. It has helped me to understand the different kinds of mental illness people live with. When I go to Kidshops, they teach me that even though someone is diagnosed with a mental illness, they are not that different, even when other kids sometimes think they are weird. They are still just kids. Kidshops has taught me how to deal with my brothers who are diagnosed with bipolar disorder, anxiety and attentiondeficit/hyperactivity disorder (ADHD). Peter, 10, who is one of the guys in the Kidshops program, has a brother with a mood disorder and he says, “sometimes when my brother tries to annoy me I ignore him and he stops. It kind of feels hard to deal with my brother sometimes, but you actually have to because you will probably always have someone in your life who annoys you.” That is one of the great things about Kidshops—I know I am not alone in how I feel and every time I go to Kidshops I look forward to seeing some of the other kids I have gotten to know. Since I have been to many Kidshops sessions, I sometimes get to be a junior leader and help with set up or with some of the games and crafts. One of the other things that helps me is my dog, Gypsy. When I am sad and when my brothers go haywire, Gypsy helps me through it and makes me happy. In Kidshops, we learn that
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Kathryn Scheele with her two brothers John (left) and Matt (right) when things get bad for us there are places for us to go, things to do like relaxation exercises or listening to music or we can talk to other kids in the program or adults who can help us. Besides playing games and doing crafts during Kidshops sessions, we get a chance to talk about our feelings, which is a big help. At the end of each Kidshops session, we get a tool to help us remember what we learned and to remind us of ways to get through the rough times. As Peter says, “my brother is always going to be in my life so it is good to learn how to deal with it now. Kidshops has helped me a lot by teaching me better ways to deal with my brother.” To learn more about Kidshops, contact Mary Jean Babcock, Kidshops project manager, NAMI Minnesota, at (651) 645-2948, ext.107 or mbabcock@nami.org or visit the NAMI Minnesota Web site at www.namihelps.org.
That is one of the greatest things about Kidshops—I know I am not alone in how I feel and every time I go to Kidshops I look forward to seeing some of the other kids I have gotten to know.
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Mental Health Screening as a Component of Integrated Care by Karen Hacker, M.D., M.P.H., executive director, Institute for Community Health and assistant professor of medicine, Harvard. Background Today, families increasingly rely on their primary care providers (PCPs) to assist them with behavioral health issues. In fact, most children with mental health issues are more likely to visit a PCP than a mental health professional (U.S. Public Health Service, 2000). A visit to a pediatrician’s office can be an opportunity to discuss emotional issues with a parent and their child. Early identification of mental health problems has the potential to help improve long-term outcomes and help children access care earlier and hopefully more readily (Williams, Klinepeter, Palmes, Pulley & Foy, 2004). Yet, while pediatricians are faced with an increased volume of cases related to mental health, they frequently under-identify mental health problems (Badger, Robinson & Farley, 1999; Richardson, Keller, SelbyHarrington & Parrish, 1996; Stancin & Palermo, 1997; Gardner et al., 2000). In addition, most pediatricians do not feel responsible for treatment or management of behavioral problems, except ADHD (Stein et al., 2008). In 1999, the U.S. Surgeon General called on pediatricians to improve screening and referral for early-onset mental illness. Today, primary care providers can play a significant role in addressing the mental health treatment needs of children, but there is still much work to be done. Screening A first step in integrating behavioral and physical health is identifying mental health problems. Recently, numerous national organizations have recommended the use of validated screening tools for this purpose. Using screening tools has been shown to increase identification of psychosocial issues (Brugman, Reijneveld, Verhulst & Verloove-Vanhorick, 2001; Murphy,
Arnett, Bishop, Jellinek & Reede, 1992). However, pediatricians note that the obstacles to screening are many and include a lack of: • time available in a visit due to productivity requirements; • resources for referral; • reimbursement for emotional health services delivered in primary care; and • skills to manage identified mental health issues effectively. A variety of standardized and validated screening tools are currently available for use in pediatric practice (Jellinek, Patel & Froehle, 2002). In general, they are simple to use and are based on self-report by parents or youth. However, screens may be specific to age and condition. At present there is no “one size fits all” solution. For example, the Modified Checklist for Autism in Toddlers (M-CHAT) is a screening tool for autism, while the Parents’ Evaluation of Developmental Status (PEDS) is a developmental and behavioral screening tool for children 0-8 years of age. Some validated tools are available free while others have an associated cost. One Experience In 2003, the Cambridge Health Alliance (CHA) began to integrate behavioral and physical health care in its pediatric clinics. CHA is an urban integrated public health system serving the communities of Cambridge, Somerville, Everett and Malden, Mass. The system has several hospitals and multiple ambulatory care clinics. There are currently nine pediatric and family medicine care sites across these communities. The Department of Pediatrics sees more than 100,000 ambulatory visits a year and the population is racially and ethnically diverse. The racial breakdown of patients is 48 percent Caucasian, 19 percent African
American, 16 percent Latino, 9 percent other, 4 percent unknown and 3 percent Asian American. We began behavioral health screening for school-aged children during their well-child visits in 2003 at one of our sites. We planned to develop and refine our process before rolling it out across CHA. We chose validated behavioral health screening tools, the Pediatric Symptom Checklist (PSC) and the Youth-PSC, because they are widely validated, simple to use, translated into numerous languages and free (Jellineck & Murphy, 2005; Murphy, Reede, Jellinek & Bishop, 1992). The PSC is a 35-item questionnaire that asks parents questions about their current behavioral and emotional concerns about their children and allows them to answer either never, sometimes or always. The Youth-PSC is for children over the age of 11 and asks the same questions from the perspective of the child. Topics range from sleeping problems to feelings of sadness and anxiety. The cutoff for concern also varies by age group. The process for screening and referral was designed to ensure minimal demands on pediatricians’ limited time (Hacker et al., 2006). It was fully carried out by existing clinic staff. The process includes the following steps: 1. Registration staff hand out the paper version of the PSC at all well-child visits. 2. Parents fill out the PSC in the waiting room. 3. Primary care physicians score the PSC in their exam rooms with the parent and child and review the score and then determine a disposition. 4. Several variables from the screen (score, parental concern, counseling and disposition) are recorded in the electronic medical record (EMR) and the screen is scanned into the record. Fall 2009 | Issue 14 | Nami Beginnings | 11
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In general, children who score positively and are not currently in counseling are referred to mental health services. In addition, children who score negatively are also referred if their parents express concern about behavioral or emotional problems. If the provider feels it is necessary, a child can be referred, regardless of score, counseling status or parental concern. Access to screening data through the EMR has allowed us to monitor compliance rates. It took over six months to get our screening compliance rates to 70 percent of eligible children. Reasons for screening noncompliance included: literacy, developmental disabilities and loss of papers. Today we have engaged all nine pediatric and family medicine sites in screening. Strategies for Screening • Prepare your practice and develop your process: As with any change in practice patterns, you will need a team approach that involves everyone in the implementation process. Determine the process for screening before you begin and decide who will give the screening tool to patients, how it will get recorded and related issues. Additional help is available on several Web sites.1, 2 • Determine which tools you want to use: There are many good resources for screening tools and information on tools is available online.3, 4 You can start with one age group and add other tools as you become more comfortable with the process. In the long run, having a standardized tool should improve efficiency in your practice. • Know your referral resources: It will be important to know when and where to refer children and to decide how much care management you want to do in your office. For example, many pediatricians now feel comfortable with a depression diagnosis and treatment. Management will require knowledge of psychopharmacology and regular
follow-up. While most insurers will accept a bill from a pediatrician for a mental health visit, reimbursement is related to the complexity of the visit, so remember to document any counseling that you do. If you choose to refer, make sure your communication is adequate to ensure that children and families do not fall through the cracks. Remember, many families may not be ready for referral and the screening process may help them think about their options. • Monitor your success: It really helps to develop reports on your screening rates and determine the percent of your population that requires additional attention. In our practices, we see about 6 percent of the population screening positively, but many are already in counseling. An additional 5 percent are referred due to either parental or provider concern even when they do not meet the cutoff for identification. • Addressing concerns about mental health with parents: In our experience, screening is a simple and efficient way to identify problems but it also provides the opportunity to discuss mental health concerns. First, the family has an opportunity to reflect on their child’s emotional health and register their concerns. Second, the provider has an opportunity to discuss the information with them and talk through options. There is newly emerging evidence that brief interventions based on motivational interviewing5 can be helpful in addressing mental health issues in primary care (Wissow, 2009). Also, various integrative strategies, such as co-location of mental health providers in your practice or access to consulting psychiatrists, can be extremely helpful. Child mental health issues are considered the “new morbidity.” There is a paucity of specialists available and the primary care community has no choice but to determine its role in this area. Screening tools can be the first step to
integrating behavioral and physical services in primary care. This integrative approach supports patient-centered care and moves us closer to the medical home model. To learn more about mental health screening as a component of integrated care, contact Dr. Karen Hacker at KHacker@challiance.org. References Badger L., Robinson H. & Farley T. (1999). Management of mental disorders in rural primary care: A proposal for integrated psychosocial services. Journal of Family Practice, 48, 813-818. Brugman E., Reijneveld S., Verhulst F. & Verloove-Vanhorick S.P. (2001). Identification and management of psychosocial problems by preventive child health care. Archives of Pediatrics and Adolescent Medicine, 155, 462-469. Gardner W., Kelleher K.J., Wasserman R., Childs G., Nutting P., Lillienfield H. & Pajer K. (2000). Primary Care Treatment of Pediatric Psychosocial Problems: A study from pediatric research in office settings and ambulatory sentinel practice network. Pediatrics, 106, 44. Hacker K., Myagmarjav E., Harris V., Franco Suglia S., Weidner D. & Link D. (2006). Screening for mental health in pediatric practice: Factors related to positive screens and the contribution of parental/personal concern. Pediatrics, 118, 1896-1906. Jellinek M., Patel B.P. & Froehle M.C. (2002). Bright Futures in Practice: Mental Health Volume I. Practice Guide, Arlington, VA. National Center for Education in Maternal and Child Health. Jellineck M. & Murphy M. (2005). Pediatric Symptom Checklist, Massachusetts General Department of Child Psychiatry. Retrieved from http://psc.partners.org/psc_detailed.htm. Accessed Sept. 11, 2005. Murphy J.M., Arnett H.L., Bishop S.J., Jellinek M.S. & Reede J.Y. (1992) Screening for psychosocial dysfunction in pediatric practice. A naturalistic study of the Pediatric Symptom Checklist. Clinical Pediatrics, 31, 660-7. Murphy J.M., Reede J., Jellinek M.S. & Bishop, S.J. (1992). Screening for psychosocial dysfunction in inner-city children: Further validation of the Pediatric Symptom Checklist. Journal of American Academy of Child and Adolescent Psychiatry, 31, 1105-1111. Richardson L.A., Keller A.M., Selby-Harrington M.L. & Parrish R. (1996). Identification and treatment of children’s mental health problems by primary care providers: A critical review of research. Archives of Psychiatric Nursing, 10, 293-303. Stancin T. & Palermo T.M. (1997). A review of behavioral screening practices in pediatric settings: Do they past the test? Journal of Developmental and Behavioral Pediatrics, 18, 183-194. Stein R.E., Horwitz S.M., Storfer-Isser A., Heneghan A.M., Olson L. & Hoagwood K.E. (2008). Do pediatricians think they are responsible for identification and management
A Developmental Screening Toolkit for Primary Care Providers is available at www.developmentalscreening.org. An Integrating Developmental Screening Worksheet is available at www.commonwealthfund.org/usr_doc/Integrating_Developmental_Screening_Worksheet.pdf. The Bright Futures Tool for Professionals Pediatric Symptom Checklist is available at www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf. 4 Information on commonly used screening tools is available at www.dbpeds.org/articles/detail.cfm?textid=539. 5 Editors Note: information on motivational interviewing can be found at www.motivationalinterview.org. 1 2 3
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A S K of child mental health problems? Results of the AAP periodic survey. Ambulatory Pediatrics, 8, 11-17. U.S. Department of Health and Human Services. (1999). Mental Health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. U.S. Public Health Service. (2000). Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. Washington, D.C. Williams J., Klinepeter K., Palmes G.,
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Pulley A. & Foy J. (2004). Diagnosis and treatment of behavioral health disorders in pediatric practice. Pediatrics, 114, 601-606. Wissow L.S., Gadomski A., Roter D., et al. (2008). Improving child and parent mental health in primary care: a cluster-randomized trial of communication skills training. Pediatrics, 121, 266-275.
Resources on the Integration of Mental Health and Primary Care Strategies to Support the Integration of Mental Health into Pediatric Primary Care An issue paper developed in 2009 by the National Institute for Health Care Management Foundation that focuses on how mental health care can be fully integrated into pediatric primary care. It reviews information on mental health programs, practices and guidelines and discusses strategies primary care providers and health plans can use to improve the early identification of mental health conditions and treatment for children in primary care. To access the issue brief, visit www.nihcm.org.
Guidelines for Adolescent Depression—Primary Care A set of guidelines developed in 2007 by the Resource for Advancing Children’s Health (REACH) Institute for the management of depression in primary care. The guidelines address issues regarding the screening, diagnosis and treatment of depression in youth. The REACH Institute has also created a tool kit for primary care physicians to support them in implementing the guidelines. To access the guidelines and tool kit, visit www.thereachinstitute.org (Click on “Resources” and then “GLADPC Toolkit”).
Best Beginning: Partnerships between Primary Health Care and Mental Health and Substance Abuse Services for Young Children and Their Families An online resource created in 2005 by the Georgetown University Center for Child and Human Development that features eight innovative medical home practices that integrate behavioral health screening for the whole family, facilitate referrals to community services and offer follow-up care. To access the resource, visit http://gucchd.georgetown.edu (Click “Products and Publications”).
Recommendations on Depression Screenings for Adolescents The U.S. Preventative Services Task Force released recommendations in 2009 urging physicians across the United States to perform routine depression screenings for adolescents between the ages of 12-18 when appropriate services are in place to ensure accurate diagnosis, treatment and follow-up care. To access the recommendations, visit www.ahrq.gov/clinic/uspstf/uspschdepr.htm.
Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration A joint position paper published in 2009 by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry that addresses the administrative and financial barriers that primary care physicians and children’s mental health professionals face in providing behavioral and mental health services to children and adolescents. To access the position paper, visit www.aap.org/mentalhealth.
Under One Roof: Primary Care Models that Work for Adolescents A report released in 2007 by The National Alliance to Advance Adolescent Health that describes a comprehensive, multidisciplinary model of physical, behavioral and reproductive health care in different health care settings. The report describes the financing challenges associated with integrated care and provides strategies to obtain additional funding support. To access the report, visit www.incenterstrategies.org (Click on “Publications” and then “Reports”).
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The Whole Health Initiative: Integrating Mental Health Into Community Health Care by Sherri Wittwer, M.P.A., executive director, NAMI Utah
AMI Utah has had a strong partnership with Intermountain Healthcare and their Mental Health Integration program for many years. As a result of the success of this partnership and the program, there was great interest in adapting Intermountain Healthcare’s model for the community. From that, the Whole Health Initiative was born. The Whole Health Initiative project is a community collaboration driven by families and individuals living with mental illness that grew out of the recognized need for mental health services for those who are underinsured or uninsured. NAMI Utah leads this project and is the fiscal agent. Other community partners who provided expertise, services or funding to develop this project include: Salt Lake County, Intermountain Healthcare, the Utah State Division of Substance Abuse and Mental Health, Valley Mental Health (the local mental health authority), the Utah State Health Department and the University of Utah Social Research Institute. The project was developed for two primary reasons: • to integrate mental health and physical health care in a single site; and • to deliver behavioral health services in an innovative and cost-effective manner that is driven by families and individuals living with mental illness. The Whole Health Initiative integrates a mental health team into existing health clinics to provide medical homes with the necessary support to
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meet the physical and mental health care needs of patients. The team consists of a psychiatric advanced practice registered nurse (APRN), a licensed clinical social worker (LCSW) and a care manager who is also a NAMI mentor. The team members work closely with frontline staff, medical assistants, physicians, patients and families to provide mental and physical health care to clinic patients.
for immediate short-term psychotherapy services from the LCSW team member or are referred to community providers for longer-term treatment. Those who are insured are assisted in finding treatment according to their insurance. Patients with severe symptoms are referred to the community mental health center for specialty mental health care. The care manager/NAMI mentor assists patients by providing
True integration of health and mental health services in a primary care setting improves access to mental health services for families in a cost-effective manner. The project is located at three low-income community health centers. At these clinics, patients are universally screened to determine whether a comprehensive mental health assessment may be needed. Physicians review these screenings and ask follow-up questions regarding patients’ mental and physical health. Patients with a positive screen are given a comprehensive packet containing standardized instruments provided by Intermountain Healthcare to detect the need for mental health services. When mental health conditions are identified, patients receive behavioral health services based on severity of need. Patients with mild symptoms receive an evaluation and treatment from the health clinic physician and a medication consultation is also made available from the APRN. Patients with moderate symptoms are also referred
information about NAMI programs and referrals to other community services for families. True integration of health and mental health services in a primary care setting improves access to mental health services for families in a costeffective manner. The primary care setting is familiar to families and stigma is less of a barrier. The focus on early identification and early intervention is key to averting crises and provides a positive approach in addressing a child’s health and mental health. To learn more about NAMI Utah’s Whole Health Initiative, contact Sherri Wittwer at sherri@namiut.org.
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Positive Connections by Stephanie Souza, M.B.A, Positive Connections program coordinator, NAMI of Greater Toledo, Ohio pproximately two-thirds of women and over one-half of men living with mental illness are parents (Nicholson, Larkin, Simon & Banks, 2001). Research suggests that children living with a caretaker with mental illness would benefit from psychosocial interventions to reduce the negative impact of the caretaker’s symtomology on child development (Silverman, 1989). In 1999, two adult children of parents living with mental illness developed the Positive Connections program. Their vision was to support future generations in combating the personal and isolating effects of living in an often unstable and unpredictable environment. This vision led to collaboration between three community organizations: NAMI of Greater Toledo, Big Brothers Big Sisters of Northwestern Ohio and Unison Behavioral Healthcare. When Positive Connections was originally created, it was a 10-week, psycho-educational program solely for children who have a parent living with a mental illness. It focused on helping children understand major mental illness and develop positive coping strategies within a nonjudgmental, supportive environment. Children who successfully completed the program were matched for a minimum of six months with a trained mentor who provided ongoing positive adult interaction. Positive Connections was embraced by the community, which has resulted in approximately 25 children being helped by the program each year for the past 10 years. Today, Positive Connections continues to be a collaborative effort between NAMI of Greater Toledo and Big Brothers Big Sisters of Northwestern Ohio. It provides education and support by helping children produce a tangible “tool box” of information and coping strategies to be called upon as needed to assist both the child and the family in managing their environment as well as their thoughts, feelings and
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I Know What Mental Illness Is by Zach, Age 10
Depressed Dog by Dominique, Age 16
actions. The program provides individualized and often interactive activities to facilitate learning and application of information. We continue to work within the original vision of the program; however, we have expanded it to include children who are struggling with their own mental, emotional or behavioral difficulties while still addressing the special issues faced by those living with a parent with mental illness. Local survey data supports this expansion. Caretakers reported in the survey that little assistance was available to help children understand their own mental illness diagnosis or a caretaker’s mental illness and related difficulties. Data from the survey also indicated that there were no programs that provided both caretaker and child support, which parents identified as a major factor to facilitate increased family participation in programs. As a result, the NAMI Child and Adolescent Network support groups for adults are now facilitated at the same time as
Positive Connections for youth to help meet the identified needs of parents. This allows for simultaneous learning and support to promote family discussion about symptomology, treatment and coping skills. Our expansion to include children living with a mental illness and parent support groups has provided us with some increased challenges in meeting the more difficult needs of these populations and has demanded that the staff be more creative. Despite our challenges, our program has grown exponentially, which we believe indicates that our programmatic changes were needed and are filling what were once unaddressed pieces of family care within the current system. We are currently evaluating how to incorporate some of the more difficult topics often faced by many who struggle with mental illness, such as suicide prevention and using drugs and alcohol as coping mechanisms. Positive Connections is a fluid program that works to conscientiously and creatively meet the ongoing, self-identified needs of our community while remaining true to the individualized spirit of each child and family. We continue to grow and change as additional needs are identified. We believe programs such as ours are needed nationally to help families thrive and grow despite the challenges they face. To learn more about Positive Connections, contact Stephanie Souza at ssouza@namitoledo.org. References Nicholson, J., Larkin, C., Simon, L. & Banks, S. (2001). The prevalence of parenting among adults with mental illness. Center for Mental Health Services Research, Department of Psychiatry, University of Massachusetts Medical School. Silverman, M.M. (1989). Children of psychiatrically ill parents: A prevention perspective. Hospital and Community Psychiatry, 40(12), 1257-1265.
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This publication is supported by McNeil Pediatrics Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. According to NAMI policy, acceptance of funds does not imply endorsement of any business practice or product.
The American Academy of Pediatrics Task Force on Mental Health
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of children’s mental health into he American Academy primary care. These resources of Pediatrics (AAP) Task include information for pediatriForce on Mental Health is developing multiple cians, physicians, families and tools and materials to policymakers. assist primary care pediatricians The task force also supports in screening, diagnosing and collaborative projects between managing the most common mental health professionals and mental health conditions within primary care physicians at the community level. The projects their practices. focus on improving mental health The AAP Task Force on referral services, developing Mental Health was developed in telemedicine programs, creating 2004 in response to the growing co-location models, developing need to address child and adowww.aap.org/mentalhealth effective mental health screening lescent mental health concerns initiatives and much more. in the primary care setting and because of the severe To learn more about the AAP Task Force on Mental Health, national shortage of child and adolescent psychiatrists. visit their Web site at www.aap.org/mentalhealth. The AAP is developing a tool kit, along with trainings, educational resources and publications on the integration
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