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Catch and Treat a Stealth Diagnosis: Obsessive-Compulsive Disorder
“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.
Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However, 
OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.1 OCD symptoms have increased since the pandemic2 so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male1 and children are most likely to be identified between ages 8-12 and during the later teenage years,3 although symptoms can occur at any time in life.
Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.4 Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.1 PTSD frequently presents with comorbid OCD symptoms.1 Finding the underlying cause is key to effective treatment.
How do I identify OCD in primary care?
Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.
How do I treat OCD in primary care?
Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.
How to access ERP?
The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.2 Interventions that include parents are most helpful for children.
Other therapy options include:
- MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
- Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
- A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
- Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.
Medication options
Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.5
Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.
2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.
3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.
“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.
Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However,
OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.1 OCD symptoms have increased since the pandemic2 so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male1 and children are most likely to be identified between ages 8-12 and during the later teenage years,3 although symptoms can occur at any time in life.
Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.4 Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.1 PTSD frequently presents with comorbid OCD symptoms.1 Finding the underlying cause is key to effective treatment.
How do I identify OCD in primary care?
Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.
How do I treat OCD in primary care?
Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.
How to access ERP?
The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.2 Interventions that include parents are most helpful for children.
Other therapy options include:
- MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
- Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
- A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
- Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.
Medication options
Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.5
Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.
2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.
3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.
“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.
Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However,
OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.1 OCD symptoms have increased since the pandemic2 so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male1 and children are most likely to be identified between ages 8-12 and during the later teenage years,3 although symptoms can occur at any time in life.
Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.4 Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.1 PTSD frequently presents with comorbid OCD symptoms.1 Finding the underlying cause is key to effective treatment.
How do I identify OCD in primary care?
Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.
How do I treat OCD in primary care?
Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.
How to access ERP?
The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.2 Interventions that include parents are most helpful for children.
Other therapy options include:
- MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
- Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
- A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
- Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.
Medication options
Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.5
Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.
2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.
3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>targeted treatment dramatically improves the life trajectory of those with OCD.</metaDescription> <articlePDF/> <teaserImage>283933</teaserImage> <teaser>Targeted treatment dramatically improves the life trajectory of those with OCD.</teaser> <title>Catch and Treat a Stealth Diagnosis: Obsessive-Compulsive Disorder</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>CPN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> <publicationData> <publicationCode>PN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> <publicationData> <publicationCode>FP</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement>Copyright 2017 Frontline Medical News</copyrightStatement> </publicationData> </publications_g> <publications> <term>9</term> <term canonical="true">25</term> <term>15</term> </publications> <sections> <term>39313</term> <term canonical="true">27729</term> </sections> <topics> <term canonical="true">248</term> <term>271</term> <term>60428</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/24010742.jpg</altRep> <description role="drol:caption">Dr. Margaret Spottswood</description> <description role="drol:credit">Dr. Spottswood</description> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Catch and Treat a Stealth Diagnosis: Obsessive-Compulsive Disorder</title> <deck/> </itemMeta> <itemContent> <p>“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice. </p> <p>Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However, <span class="tag metaDescription">targeted treatment dramatically improves the life trajectory of those with OCD.</span><br/><br/>[[{"fid":"283933","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt; she is the medical director of the Vermont Child Psychiatry Access Program.","field_file_image_credit[und][0][value]":"Dr. Spottswood","field_file_image_caption[und][0][value]":"Dr. Margaret Spottswood"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]]OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.<sup>1</sup> OCD symptoms have increased since the pandemic<sup>2</sup> so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the <span class="Hyperlink"><a href="https://www.mcpap.com/pdf/CYBOCS.pdf">Children’s Yale-Brown Obsessive Compulsive Scale</a></span> (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male<sup>1</sup> and children are most likely to be identified between ages 8-12 and during the later teenage years,<sup>3</sup> although symptoms can occur at any time in life. <br/><br/>Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.<sup>4</sup> Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.<sup>1</sup> PTSD frequently presents with comorbid OCD symptoms.<sup>1</sup> Finding the underlying cause is key to effective treatment.<br/><br/></p> <h2>How do I identify OCD in primary care?</h2> <p>Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD. </p> <h2>How do I treat OCD in primary care? </h2> <p>Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy. </p> <h2>How to access ERP?</h2> <p>The International OCD Foundation offers a <span class="Hyperlink"><a href="https://kids.iocdf.org/professionals/mh/about-erp-for-pediatric-ocd/">list of therapists</a></span> trained in ERP, and most states’ <span class="Hyperlink"><a href="https://www.nncpap.org/map">psychiatry access lines</a></span> can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent <em>JAMA</em> article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.<sup>2</sup> Interventions that include parents are most helpful for children. <br/><br/>Other therapy options include:</p> <ul class="body"> <li>MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found <a href="https://events.iocdf.org/event/9e54a18c-5ca8-44ef-ba3b-6a83c3389b05/summary?RefId=conference-series&_ga=2.202302358.628288012.1700498194-242574322.1700498194">here</a>. </li> <li>Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option. </li> <li>A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson. </li> <li>Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP. </li> </ul> <h2>Medication options </h2> <p>Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.<sup>5</sup> <br/><br/>Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at <span class="Hyperlink"><a href="https://iocdf.org/">iocdf.org</a></span>. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.<br/><br/></p> <p> <em>Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.</em> </p> <h2>References</h2> <p>1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. <span class="Hyperlink"><a href="https://www.nature.com/articles/mp200894">doi: 10.1038/mp.2008.94</a></span>. <br/><br/>2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. <span class="Hyperlink"><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790052">doi: 10.1001/jamanetworkopen.2022.1978</a></span>.<br/><br/>3. International OCD Foundation pediatric OCD for professionals. <a href="https://kids.iocdf.org/professionals/md/pediatric-ocd/">https://kids.iocdf.org/professionals/md/pediatric-ocd/</a>. Accessed December 27, 2023. <br/><br/>4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. <span class="Hyperlink"><a href="https://doi.org/10.1176/appi.books.9780890425596">https://doi.org/10.1176/appi.books.9780890425596</a>. </span>Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.</p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
‘Never worry alone:’ Expand your child mental health comfort zone using supports
That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.
Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, . This moment in time seems like a great opportunity to review a few favorites.
Who you gonna call?
Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!1 If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.
What about screening?
The AAP has an excellent mental health minute on screening.2 Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.
Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.3 A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
Treating to target?
When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.
Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s4 and Virginia’s5), and the AACAP parent medication guides.6 They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.7 Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”8 specific symptoms until they improve.
How to provide help with few resources?
There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”9 even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook10 or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.
What about connections for us providers?
Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.
And finally ...
So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.
Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.
References
1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.
2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.
3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.
4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.
5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.
6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.
7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.
8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.
9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.
10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.
That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.
Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, . This moment in time seems like a great opportunity to review a few favorites.
Who you gonna call?
Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!1 If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.
What about screening?
The AAP has an excellent mental health minute on screening.2 Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.
Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.3 A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
Treating to target?
When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.
Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s4 and Virginia’s5), and the AACAP parent medication guides.6 They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.7 Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”8 specific symptoms until they improve.
How to provide help with few resources?
There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”9 even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook10 or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.
What about connections for us providers?
Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.
And finally ...
So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.
Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.
References
1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.
2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.
3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.
4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.
5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.
6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.
7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.
8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.
9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.
10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.
That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.
Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, . This moment in time seems like a great opportunity to review a few favorites.
Who you gonna call?
Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!1 If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.
What about screening?
The AAP has an excellent mental health minute on screening.2 Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.
Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.3 A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
Treating to target?
When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.
Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s4 and Virginia’s5), and the AACAP parent medication guides.6 They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.7 Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”8 specific symptoms until they improve.
How to provide help with few resources?
There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”9 even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook10 or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.
What about connections for us providers?
Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.
And finally ...
So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.
Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.
References
1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.
2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.
3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.
4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.
5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.
6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.
7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.
8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.
9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.
10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>there are some key resources available now that can be used by child psychiatrists and pediatricians alike</metaDescription> <articlePDF/> <teaserImage>283933</teaserImage> <teaser>There are supports available to better facilitate the interface between mental health and primary care. </teaser> <title>‘Never worry alone:’ Expand your child mental health comfort zone using supports</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2023</pubPubdateYear> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>PN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term canonical="true">25</term> </publications> <sections> <term canonical="true">27729</term> </sections> <topics> <term canonical="true">248</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/24010742.jpg</altRep> <description role="drol:caption">Dr. Margaret Spottswood</description> <description role="drol:credit">Margaret Spottswood</description> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>‘Never worry alone:’ Expand your child mental health comfort zone using supports</title> <deck/> </itemMeta> <itemContent> <p>That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about. </p> <p><span class="Hyperlink">[[{"fid":"283933","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt; she is the medical director of the Vermont Child Psychiatry Access Program.","field_file_image_credit[und][0][value]":"Margaret Spottswood","field_file_image_caption[und][0][value]":"Dr. Margaret Spottswood"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]]<a href="https://www.mdedge.com/pediatrics/article/262805/mental-health/integrating-mental-health-and-primary-care-dipping-toe?channel=27729">Dr. Rettew’s column</a></span> last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, <span class="tag metaDescription">there are some key resources available now that can be used by child psychiatrists and pediatricians alike</span>. This moment in time seems like a great opportunity to review a few favorites.<br/><br/></p> <h2>Who you gonna call?</h2> <p>Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost <span class="Hyperlink"><a href="https://www.nncpap.org/map">everywhere</a></span>!<sup>1</sup> If you haven’t called one yet, click on <span class="Hyperlink"><a href="https://www.nncpap.org/map">your state</a></span> and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.</p> <h2>What about screening? </h2> <p>The AAP has an excellent <span class="Hyperlink"><a href="https://www.aap.org/en/patient-care/mental-health-minute/screening-tools/">mental health minute on screening</a></span>.<sup>2</sup> Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.</p> <p>Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as <span class="Hyperlink"><a href="https://projectteachny.org/child-rating-scales/">New York’s</a></span>.<sup>3</sup> A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier! <br/><br/></p> <h2>Treating to target?</h2> <p>When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit. </p> <p>Some favorite treatment resources include the CPAP guidebook from your state (for example, <span class="Hyperlink"><a href="https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf">Washington’s</a></span><sup>4</sup> and <span class="Hyperlink"><a href="https://vmap.org/guidebook/">Virginia’s</a></span><sup>5</sup>), and the <span class="Hyperlink"><a href="https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx">AACAP parent medication guides</a></span>.<sup>6</sup> They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the <span class="Hyperlink"><a href="https://www.appi.org/Products/Child-and-Adolescent-Psychiatry/DSM-5-Pocket-Guide-for-Child-and-Adolescent-Mental?sku=37051">DSM 5 Pocket Guide for Child and Adolescent Mental Health</a></span>.<sup>7</sup> Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “<span class="Hyperlink"><a href="https://aims.uw.edu/resource-library/measurement-based-treatment-target">treat to target</a></span>”<sup>8</sup> specific symptoms until they improve. <br/><br/></p> <h2>How to provide help with few resources?</h2> <p>There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “<span class="Hyperlink"><a href="https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf">special time</a>,</span>”<sup>9</sup> even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) <span class="Hyperlink"><a href="https://www.simonandschuster.com/books/Standing-Up-to-OCD-Workbook-For-Kids/Tyson-Reuter/Health-and-Wellness-Workbooks-for-Kids/9781641527972">workbook</a></span><sup>10</sup> or look at the <span class="Hyperlink"><a href="https://iocdf.org">iocdf.org</a></span> website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps. </p> <h2>What about connections for us providers?</h2> <p>Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected. </p> <h2>And finally ...</h2> <p>So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better. </p> <p> <em>Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.</em> </p> <h2>References</h2> <p>1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. <span class="Hyperlink"><a href="https://www.nncpap.org/map">https://www.nncpap.orgmap</a></span>. 2023 Mar 14.<br/><br/>2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. <span class="Hyperlink"><a href="https://www.aap.org/en/patient-care/mental-health-minute/screening-tools/">https://www.aap.org/en/patient-care/mental-health-minute/screening-tools</a></span>. <br/><br/>3. New York ProjectTEACH. Child Clinical Rating Scales. <span class="Hyperlink"><a href="https://projectteachny.org/child-rating-scales/">https://projectteachny.org/child-rating-scales</a></span>. <br/><br/>4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. <span class="Hyperlink"><a href="https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf">https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf</a></span>. <br/><br/>5. Virginia Mental Health Access Program. VMAP Guidebook. <span class="Hyperlink"><a href="https://vmap.org/guidebook/">https://vmap.org/guidebook</a></span>. <br/><br/>6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. <span class="Hyperlink"><a href="https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx">https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx</a></span>.<br/><br/>7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.<br/><br/>8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. <span class="Hyperlink"><a href="https://aims.uw.edu/resource-library/measurement-based-treatment-target">https://aims.uw.edu/resource-library/measurement-based-treatment-target</a></span>. <br/><br/>9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. <span class="Hyperlink"><a href="https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf">https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf</a></span>. <br/><br/>10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019. </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>