Introduction Managing Mental Health Concerns in Pediatrics: A Clinical Support Chart is a point-of-care aid to pediatric clinicians—both generalists and subspecialists—for use in responding to the mental health needs they uncover in their everyday practice: positive results on psycho- social screenings, parental concerns, symptoms, impaired functioning, exposure to trauma, and social adversities. It highlights brief, evidence- based, “transdiagnostic” interventions that address these needs, efficiently, in pediatric settings. The American Academy of Pediatrics (AAP), in its policy statement “Mental Health Competencies for Pediatric Practice” (Pediatrics, November 2019), describes promising adaptations of these trans- diagnostic approaches for use in pediatrics. Examples include “common factors” communication techniques, which apply to a range of problems that are not causally related, and “common elements,” semi-specific components of psychosocial therapies, which apply to a group of related conditions. As quoted from the AAP statement: The goals of brief therapeutic interventions for children and adolescents . . . are to improve the patient’s functioning, reduce distress in the patient and parents, and potentially prevent a later disorder. For children and adolescents identified as needing mental health and/or developmental-behavioral specialty involvement, goals of brief interventions are to help overcome barriers to their accessing care, to ameliorate symptoms and distress while awaiting completion of the referral, and to monitor the patient’s functioning and well-being while awaiting higher levels of care. Brevity of these interventions, ideally no more than 10 to 15 minutes per session, mitigates disruption to practice flow. Also in the AAP mental health competencies statement is an algorithm representing a process for integrating mental health care into the flow of pediatric practice. (See the “Mental Health Care in Pediatric Practice” figure on the following page.) Managing Mental Health Concerns in Pediatrics follows its logic, with the following guidance to assist in decision-making: X Tab 1, “Causes for Concern,” points the clinician to clinical findings that require a response. (Corresponds with algorithm steps in red.) X Tab 2, “First Response,” guides the clinician in using “common factors” communication skills to build a bond of trust with the child and family, address barriers to their seeking help, and ready them for further steps in assessing and caring for the child—a universal approach that has been proved beneficial, across a wide range of mental health concerns, in reducing the family’s distress and im- proving the child’s functioning. Additional tools help the family, as a whole, achieve better mental health and take advantage of reliable self-help resources. (Corresponds with algorithm step 11.) X Tab 3, “Next Steps,” describes the decision-making process that follows. It relies on the kind of iterative assessment that is typical of pediatric practice: data collection takes place over the course of one or several brief pediatric visits and often includes information gathered between visits from caregivers and school personnel. The chart then provides guidance for making decisions about further care: (1) whether the child needs a specialist for diagnostic eval- uation (2) whether the child may benefit from a psychotropic drug (3) whether and how to involve specialists in treatment and (4) respective roles of pediatric clinicians and specialists in the care plan. (Corresponds with algorithm steps in yellow.) X Tab 4, “Symptomatic Care,” offers guidance for managing common mental health symptoms. The guidance applies to those children whose care does not require specialty involvement, those whose families are not yet ready or able to seek needed specialty care, and those who are ready and awaiting specialty care. The tab is organized into 8 sets of symptoms: emotional or behavioral prob- lems in children younger than 5 years inattention, impulsivity, and hyperactivity medically unexplained symptoms anxiety and trauma-related distress depressive symptoms disruptive behavior and aggression substance use and learning difficulty. Each section outlines for the clinician what to look for in the assessment and describes interventions that can be delivered within brief pediatric encounters. (Corresponds with algorithm step 11.) The AAP recognizes the diversity of lifestyles and family arrangements. Except where noted, advice in this publication applies to parents (both single- and 2-parent households), spouses, partners, grandparents, and other types of caregivers. We are dedicated to supporting pedia- tric clinicians in delivering the highest-quality care achievable and to addressing the great unmet need for child and adolescent mental health care. The colorful, easy-to-read pages in this chart, adapted largely from the AAP peer-reviewed textbook Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians, aim to make the core principles of the textbook accessible to clinicians and clinicians-in-training, as they provide care. We hope you find this resource to be valuable to you and the families you serve. Acknowledgments I am deeply grateful to the many authors who contributed to the AAP mental health textbooks, Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians and Promoting Mental Health in Children and Adolescents: Primary Care Practice and Advocacy (both, 2018), and to the recently updated mental health Point-of- Care Quick Reference topics from Pediatric Care Online (PCO, 2021). These colleagues’ wisdom and expertise underlie this flip chart as well. I am also indebted to our thoughtful reviewers: Alain Joffe, MD, MPH, FAAP Marian Earls and Cori Green on behalf of the AAP Mental Health Leadership Work Group (MHLWG) John Takayama for the AAP Section on Developmental and Behavioral Pediatrics (SODBP) Sharon Levy and Joanna Quigley for the AAP Committee on Substance Use and Prevention (COSUP) and Parwaiz Rashidzada for the AAP Section on Tobacco Control (SOTCo). Their input was invaluable in ensuring this chart’s relevance to clinicians across pediatric settings. This chart would not have been possible without the efforts of dedicated AAP staff: in particular, Carrie Peters, who recognized the potential of this chart format to support pediatric clinicians in mental health decision-making at the point of care and who shepherded this chart from concept to publication, and Linda Paul, who coordinated this project with the numerous other AAP mental health initiatives. I have been privileged to work with such patient, wise, and committed professionals. It is our collective hope that this flip chart will make critical content of the mental health textbooks and PCO accessible to both primary care clinicians and subspecialists, as they work to identify and address the mental health needs of children and adolescents. Jane Meschan Foy, MD, FAAP i MMHC - INTERIOR - FLIP CHART - PORTRAIT.indd 1 5/14/21 3:09 PM
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