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More than Just a Tummy Ache: Collaborative Primary Care and Behavioral Health Approaches. Head to Toe 14 Preconference Breakout Session “H” Dan Rifkin, MD & Mary M. Ramos, MD, MPH April 13, 2010 Albuquerque. Presenters. Mary M. Ramos, MD, MPH, FAAP

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more than just a tummy ache collaborative primary care and behavioral health approaches

More than Just a Tummy Ache: Collaborative Primary Care and Behavioral Health Approaches

Head to Toe 14 Preconference Breakout Session “H”

Dan Rifkin, MD & Mary M. Ramos, MD, MPH

April 13, 2010

Albuquerque

presenters
Presenters

Mary M. Ramos, MD, MPH, FAAP

Office of School and Adolescent Health (NM DOH)

Research Assistant Professor of Pediatrics

University of New Mexico—School of Medicine

Dan Rifkin, MDChild & Adolescent Psychiatrist

Envision New Mexico

UNM School-Based Health Centers

Pediatric Clinic, UNM-Health Sciences Center

Asst Professor of Pediatrics and Psychiatry,

University of New Mexico School of Medicine

goals
Goals

Integrated Medical and Mental Health Care

Collaborative Assessment and Treatment

objectives
Objectives

1) Appreciate how the integration of medical and mental health care benefits students

2) Recognize several (9+) ways the mind-body interface presents clinically

3)Anticipate psychiatric comorbiditycommonly found in students

4) Outline three realms of collaborative care

5)Select ways to integrate care involving empirically supported approaches to assessment and treatment of psychiatric comorbidity frequently encountered in youth

integrated medical mental healthcare does it really benefit students 1 st ob j ective
Integrated Medical & Mental Healthcare Does it really benefit students?1st Objective

Appreciate how the integration of medical and mental health care benefits students

slide6
Valuing the

Integration of

Health & Behavioral Health Care

who said so
Who Said so…
  • The U.S. Surgeon General has stated that the connection between mind and body are closely related (1999).
  • SBHC Primary Care and Behavioral Health Providers have a lot to say and do about the mind-body connection!!!
history
History
  • Remote:Ancient Greeks: Hippocrates et al. believed physiologic & mental state determined by mixture (balance/imbalance) of four humors (Black Bile, Phlegm, Yellow Bile, Blood)
  • Recent:BioPsychoSocial model, ca.1970s-80s, by internist/psychiatrist George Engel, MD Offers explanations for:
    • Heart Disease, Asthma, and other medical illnesses
    • Depression, Anxiety, Subst. Abuse/Dep, and other psychiatric disorders
separating mind from body
Separating Mind from Body
  • Separation of Mind [“Psyche”] from Body [“Soma”] has become a useful, convenient construct for conceptualizing illness and appropriating care
  • Separation limits effective health & mental health care!
  • Without care integration, psychiatric comorbidity can be under-recognized during primary health care and, conversely, medical problems under-recognized during mental health care.
integrating medical mental health care
Integrating Medical & Mental Health Care
  • SBHCs aim to integrate medical and mental health care in order to assess and treat youth comprehensively.
  • Standard of care in SBHCs
    • Care integration has become the standard set for SBHCs in New Mexico, by OSAH, and nationally, by NASBHC.
    • NASBHC developing Integrated Care position statement
  • Beyond our SBHCs, appreciated by school providers, educators, and families
  • Compatible with the clinically useful BioPsychoSocial model
nasbhc developing position statement on integrated care
NASBHC Developing Position Statement* on Integrated Care
  • Integration of primary care and mental health services expected in SBHCs, as standard of care
  • Expanding traditional roles, sharing competencies across disciplines
  • Provide operational processes for combining mental health and primary care services regarding documentation, communication, visits, referrals, and shared responsibilities
  • Insurance (Medicaid, SCHIP, commercial) reimbursement for integrated SBHC services
  • Integrated practice training for primary care and mental health providers {*2008 Draft being revised}
frequently seen in sbhcs
Frequently Seen in SBHCs

Conditions/Diagnoses with intertwined medical and psychosocial {BioPsychoSocial} etiologies & risk factors that benefit from integrated care:

  • Asthma
  • Overweight
  • Depression
  • Anxiety
  • Pregnancy
  • Substance Abuse/Dependence
how does the mind body interface emerge ob j ective
? How does the mind-body interface emerge ?Objective

Recognize several (9)

ways the mind-body interface presents clinically

preamble
Preamble
  • Physiologic regulation is influenced by psychologic state (and vice versa) in humans.
  • Most organ systems and many medical conditions are stress sensitive (Kazura, Boris, & Dalton). Contrariwise, physiologic disequilibrium and medical illness profoundly impact the psyche.
psychosomatic syndromes
Psychosomatic Syndromes

Bodily Symptoms

develop

during

Mental Health Disruption

1 classic psychiatric disorders distinguished by prominent physical symptoms
1) “Classic” psychiatric disorders**{distinguished by prominent physical symptoms}

a) Somatoform Disorders--include:

Somatization Disorder

Conversion Disorder (e.g. pseudoseizures)

Hypochondriasis

Physical symptoms/complaints without objective “organic” causes/signs

Unconscious expression of psychological stress/conflict through body

b) Factitious Disorder: a.k.a.“Munchausen Syndrome”

Symptoms & signs produced by patient or someone else (“by proxy”)

Differs from deceptive Malingering (psychiatric Ddx; DSM-IV, v65.2)

**2 of 3 broad categories of psychosomatic disorders distinguished in DSM-IV

  • Result in medical care seeking, yet…
  • Rare in school-based health care; following conditions more common in students…
2 somatic features of common psychiatric disorders
2) Somatic features of common psychiatric disorders:

a) Depressed and Anxious youth often present with headache, GI upset, backache, and fatigue

b) Generalized anxiety disorder (GAD) causing muscle tension and fatigability (DSM)

c) Panic attack symptoms: palpitations, SOB/smothering, chest tightness or pain, sweating, trembling, paresthesias, nausea/abdominal distress, feeling of choking, feeling dizzy, lightheaded, unsteady, or faint, etc (DSM); in panic disorder, PTSD, depression

d) Eating disorders: multiple physiologic problems due to anorexia, binging, and purging

how frequent are somatic symptoms among adolescents
How frequent are somatic symptoms among adolescents?

Headache?

Stomachache?

Backache?

Morning fatigue?

symptoms frequently reported us adolescent girls
Symptoms Frequently Reported*US Adolescent Girls

Headache 29%

Stomachache 21%

Backache 24%

Morning fatigue 31%

*More than once/week

(Arch Pediatr Adolesc Med 2004;158:797-803)

are somatic symptoms related to social stressors yes
Are somatic symptoms related to social stressors?YES !

Very low parent support

Very low teacher support

Bullying at least once/wk

Associated with: Headache, Stomachache, Backache, Morning fatigue

(Arch Pediatr Adolesc Med 2004;158:797-803)

frequent somatic symptoms during previous 6 months finnish students 16 18 years old
Frequent Somatic Symptoms During Previous 6 Months--Finnish Students, 16-18 years old

Females (%)Males (%)

Headache 227

Abdominal Pains 13 5

Fatigue or Weakness 38 22

Lethargy 34 24

Difficulty Sleeping 22 16

(Pediatrics 1995;96:59-63)

life events associated with higher somatic symptom scores female students
Life Events associated with Higher Somatic Symptom Scores – Female Students

Serious illness or injury in family

Increased number of arguments between parents

Failing an examination

Breaking up with boyfriends or girlfriends

Also associated:

Depression/Anxiety trait

High relief alcohol or drug use

(Pediatrics 1995;96:59-63)

life events associated with higher somatic symptom scores male students
Life Events associated with Higher Somatic Symptom Scores – Male Students

Increased absence of a parent from home

Trouble with siblings

Failing an examination

Also associated:

Depression/Anxiety trait

High relief alcohol or drug use

(Pediatrics 1995;96:59-63)

recurrent abdominal pain anxiety and depression in primary care
Recurrent Abdominal Pain, Anxiety, and Depression in Primary Care
  • Recurrent abdominal pain (RAP) associated with anxiety and depression in youth.
  • Students who present with RAP in (school-based health) care deservecareful assessment for anxiety and depressive disorders.
    • Campo JV, Bridge J, Ehmann M, Altman S, Lucas A, Birmaher B, Di Lorenzo C, Iyengar S, Brent DA (2004), Recurrent Abdominal Pain, Anxiety, and Depression in Primary Care.Pediatrics 113(4):817-24 (Western Psychiatric Institute and Clinic; Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center)
slide26
RECURRENT ABDOMINAL PAIN, HEADACHE AND LIMB PAINS IN CHILDREN AND ADOLESCENTSPediatrics, Sep 1972; 50: 429 - 436
  • prevalence of recurrent abdominal pain 14.4% headache 20.6%

growingpains15.5%

  • eight-year long longitudinalstudy
  • nonselected population of school children

Jakob Øster M.D.

Department of Pediatrics, The Central Hospital, Randers, Denmark

3 psychophysiologic syndromes
3)“Psychophysiologic”syndromes

Preamble:From the bronchial constriction in asthma to the weal and flare skin response in uticaria (hives), there are many examples of chronic and recurring conditions whose physiologic course is related to psychologic adjustment.

(Kazura, Boris, & Dalton)

3 psychophysiologic syndromes1
3) Psychophysiologic syndromes
  • Medical illness affected by psychosocial stressors

Examples: asthma; headaches; eczema; irritable bowel syndrome

  • “Psychological Factors Affecting Medical Condition” (316) **3rd broad DSM-IVcategory of Psychosomatic disorders**

“[Specified Psychological Factor]Affecting[Indicate the General Medical Condition]”

Psychologically meaningfulfactor(s) temporally related to the initiation or exacerbation of a specified physical/medical condition.

Varieties: chosen name based on the nature of the psychological factors:

-Psychological Symptoms Affecting…

e.g. anxiety precipitating tension headache or recurrence of a migraine

-(Psychosocial) Stress-Related Physiologic Response Affecting…

e.g. break-up with boy/girlfriend during final exams exacerbating asthma

(precipitating “asthma attack”)

-Personality Traits or Coping Style Affecting…

-Maladaptive Health Behaviors Affecting… e.g. overeating; no exercise; unsafe sex

-Other psychological factors: e.g. interpersonal, cultural, or religious factors

somatopsychic syndromes
“Somatopsychic” Syndromes

Mental Health Disruption

develops during

Medical & Physiologic Conditions

4 medical mimics
4) “Medical Mimics”

Preamble:

Myriad of (a) medical conditions and (b) medications produce psychiatric disorders in youth, including depression, anxiety, psychosis, and disruptive behaviors

4 medical mimics1
4) Medical Mimics

a) a.k.a.Psychiatric Disorder Due to a General Medical Condition (DSM-IV293.xx)

Depressive Disorder Endocrine (e.g. hypo/hyperthyroidism)

Anxiety Disorder….. Metabolic

Psychotic Disorder Infections

Hematologic (e.g. anemia)

Neoplastic (cancer)

Neurologic (e.g. seizures)

Examples: Depressive Disorder due to hypothyroidism (relatively common)

Anxiety Disorder due to hyperthyroidism, tumors (pheochromocytoma-rare), cardiovascular disease (arrhythmias)

5 psychiatric disorder exacerbated by physiologic factors
5) Psychiatric disorder exacerbated by physiologic factors
  • Milder version of 4a) Medical Mimics
  • Examples: Depression (MDE) associated with subclinical hypothyroidism {high nl. TSH (+/- low nl FT4)}

Depression following pregnancy (postpartum depression); perhaps alleviated during pregnancy

combined
Combined

“Psyche”

-and-

“Soma”

Factors

4 medical mimics2
4) Medical Mimics

b) Medication-induced:

Examples:

Rx dextroamphetamine-induced psychosis associated with, GI upset, headaches, decreased appetite & weight, and elevated pulse & BP

Rx propranolol-induced depression associated with psychomotor slowing and lower pulse & BP

6 substance induced disorders
6) Substance-Induced Disorders
  • Drugs & Alcohol can produce psychiatric and medical illness
  • Substance-Induced Psychiatric Disorders: mood, anxiety, psychosis, delirium, sleep
  • Methamphetamine dependence resulting in psychotic and depressive features, HCV infection, malnutrition, skin lesions, dental decay
7 physiologic states with intertwined health and mental health vulnerability
7) Physiologic states with intertwined health and mental health vulnerability
  • Pregnancy
  • Puberty
  • Malnutrition (acute or chronic; not due to eating do)
  • Sleep deprivation
8 seemingly unrelated health medical need
8)Seemingly Unrelated Health/Medical Need
  • Depression &/or anxiety revealed during sports physical
  • Psychosis (audio hallucinations & paranoid ideation) found when seen for musculoskeletal discomfort
9 comorbid co existing medical and psychiatric conditions
9) Comorbid/Co-existing Medical and PsychiatricConditions
  • Asthma, overweight, and other medical conditions often co-occur with psychiatric disorders in youth
  • Examples:

-Asthma co-existing with anxiety disorder {chronic psychophysiologic syndrome}

{Cf. Asthmatic exacerbation (“asthma attack”) presenting with panic attack (2c above)}

    • Can co-exist with depressive disorder

-Overweight student with depression

psychiatric conditions in children with asthma
Psychiatric Conditions in Children with Asthma
  • More behavioral/emotional problems in asthmatic children than healthy children -and- those with other chronic illness.
  • Metaanalysis of 26 studies, involving 4923 children, 4-19 yrs
    • McQuaid (2000), Society Developmental & Behavioral Peds Annl Mtg
  • Parent reports indicated significant increases in both internalizing symptoms (depression & anxiety) –and- externalizing symptoms (aggression and oppositionality)
    • both proportional to asthma severity (7 studies examined)
psychiatric conditions in children with asthma1
Psychiatric Conditions in Children with Asthma
  • Metaanalysis of 26 studies, involving 4923 children, 4-19 yrs
    • McQuaid (2000), Society Developmental & Behavioral Peds Annl Mtg
  • Difference between children’s and parental perceptions/reports
    • No increased anxiety or depression found in children’s self-reports of internalizing symptoms (8 studies examined)
    • Suggests/implies importance of always asking parents/guardians about asthmatic students’ behavior and moods
9 ways the mind body interface presents clinically
9 ways the mind-body interface presents clinically

1) “Classic” Psychosomatic Syndromes

2) Somatic features of common psychiatric disorders

3) “Psychophysiologic” syndromes

4) “Medical Mimics”– a) medical conditions and b) medications

5) Psychiatric disorder exacerbated by physiologic factors {milder version of 4a) Medical Mimics}

6) Drugs and Alcohol can produce psychiatric and medical illness

7) Physiologic states with intertwined health & mental health vulnerability

8) Seemingly Unrelated Health/Medical Need

9) Comorbid /co-existing medical and psychiatric conditions

do psychiatric conditions commonly co exist ob j ective
? Do psychiatric conditions commonly co-exist ?Objective

Anticipate psychiatric comorbidity commonly found in students

depression is common
Depression is Common!
  • One of the most serious and common problems encountered by youth of all ages.
  • E.g, in the 2007 NM Youth Risk and Resiliency Survey (YRRS), of students in grades 9-12:
    • 30.8% had persistent feelings of sadness or hopelessness
    • 19.3% seriously considered attempting suicide
    • 14.3% attempted suicide one or more times
depression can be present in students with
Depression can be present in students with:

Headaches, stomach aches, and other somatic complaints (especially elem. & middle school)

Chronic/recurrent medical illness, e.g. asthma and diabetes

Obesity/overweight (inextricable association)

Substance abuse

Suicidal thoughts (major depressive episode symptom)

ADHD and other conditions causing distractibility, impulsivity, and hyperactivity

Experienced trauma and important loss

frequent depression comorbidity
Frequent Depression Comorbidity
  • Anxiety Disorders, including PTSD
  • Substance abuse/dependence
    • Often co-occurs with depression in youth
    • Also, with ADHD, bipolar disorder, PTSD, other anxiety disorders, conduct disorder, etc.
    • More than in adults!!!
  • Anticipate comorbid/coexisting psychiatric disorders!!
who collaborates on care for student success ob j ective
? Who collaborates on care for student success ?Objective

Outline three realms of

collaborative care

>Need to begin with Cooperation !!!

sbhc collaborative care overview
SBHC Collaborative Care Overview
  • Integration within our SBHC
  • Collaboration with the School
  • Coordination with Community Providers/Agencies
collaborative care
Collaborative Care

Overlapping care domains!

SchoolCommunity Provider/Agency

/Program

SBHCenter

collaborative care summary
Collaborative Care Summary
  • Integration within our SBHC
    • Care integrationinvolving PCP, therapist, consulting psychiatrist et al. SBHC team
  • Collaboration with School providers
    • with school team {nurse, counselor(s), social worker(s), psychologist(s), others}
  • Coordination with Community Providers/Agencies

Team meeting process vital to assessment & tx!!

summary collaborative care
Summary: Collaborative Care

Working together in our SBHCs, through collaboration with multiple school professionals, and by coordinating care with community agencies/providers, we can do more to assess and treat student mental health issues.

how is care integrated objective
? How is care integrated ?Objective

Select ways to integrate care involving empirically supported approaches to assessment and treatment of psychiatric comorbidity frequently found in students

tools for integrating care
Tools for Integrating Care*

Screening tools

Student Health Questionnaire (SHQ)

multiphasic risk & resiliency factors screen

Assessment instruments

Modified PHQ-9, or other assessment, for depression

SBHC Health Maintenance Record

OSAH Standards & Benchmarks

set expectations for integrated care

*See Handouts and RESOURCES: Tools and Websites (below)

depression screening in adolescents how are providers doing
Depression Screening in Adolescents– How are Providers doing?

Primary Care Providers often overlook mental health problems in the adolescent population.

depression screening in adolescents how are providers doing1
Depression Screening in Adolescents– How are Providers doing?

Survey of pediatricians and family physicians in MD

47% encountered 1 or more adolescents who attempted suicide in the past year

Only 23% frequently or always screened adolescent patients for suicide risk factors

(Arch Pediatr Adolesc Med 2000:154:162-168)

depression screening in adolescents how are providers doing2
Depression Screening in Adolescents– How are Providers doing?

Survey of pediatricians within HMO in CA

17% reported they screened for depression at all adolescent prevention services visits

15% reported they screened for suicide risk factors at all adolescent prevention services visits

(Arch Pediatr Adolesc Med 2000:154:173-179)

depression screening in adolescents how are providers doing3
Depression Screening in Adolescents– How are Providers doing?

Survey of providers working at community health centers in multiple states

64% reported they usually screened for depression at adolescent prevention services visits

53% reported they usually screened for suicidal thoughts at adolescent prevention services visits

(Pediatrics 2001:107(2):318-327)

depression screening in adolescents why is this important for pcps
Depression Screening in Adolescents– Why is this important for PCPs?

Half of adolescents making suicide attempts receive medical care in the month prior to the attempt.

One quarter seek care in the week preceding the attempt.

It is an error of omission not to screen.

(Ann Emerg Med 1997;29:141-145)

using tools for integration
Using Tools for Integration
  • One chart, opens to Student Health Maint. Rec.
  • One screening tool (SHQ) and one assessment instrument for both behavioral health and medical providers (e.g. PHQ-9 for depression)
  • Team meeting/conferencing
  • Chart reviews
  • Guidelines for the Management of Depression (“Depression Guidelines”)

>See Resources: Tools & Websites below<

chart review purposes
Chart Review Purposes
  • QA – following OSAH Stds & B-marks & Medicaid standards
  • SBHC team internal review, to follow best practice clinical guidelines for depression (also for Asthma and EPSDT)
  • QI – example in next slide

>See Resources: Tools & Websites below<

envision nm sbhc bh qi initiative
Envision NM SBHC BH-QI Initiative

1) Screen w/ SHQ: SBHCs administer the Student Health Questionnaire (SHQ) on the first student visit; by the third visit if the student is acutely ill or in crisis during the initial visit (OSAH Std. 16.2).

2) Assess +screens w/ PHQ-9 or other depression assessment if indicated by results of the SHQ.

3) Team conferencing about further assessment & treatment plan development.

tuesday a m in our sbhc case
Tuesday a.m. in our SBHC{Case}
  • Findings:
    • SHQ; >> PHQ-9 (Mod.) if indicated
    • Hx
    • MSE
    • PE
    • Labs
  • A/Dx
  • Multimodal Tx Plan
clinical pearls for pcps
Clinical Pearls for PCPs

“Common Things are Common!”

If you’re not thinking about it, you’ll never see it. (Consider depression/anxiety in the DDX).

Correlate of above: Consider a broad DDX early; don’t make depression or anxiety simply a diagnosis of exclusion.

90% of the diagnosis is from the history; the physical exam is just to confirm.

So,…Use Screening tools as important part of routine practice.

empirically supported approaches
Empirically-Supported Approaches

Avoid “all in your head” comments.

Consider possible depression, anxiety, and other possibilities early, rather than by exclusion

Foster supportive, consistent, professional relationship.

Avoid false (impulsive) reassurances & promises.

Include psychoeducational interventions.

Avoid pharmacotherapy as a quick fix; Rx part of comprehensive treatment plan.

Practice Integrated and Collaborative Care

collaborative care applied
Collaborative Care Applied

(1)Care integration within our SBHC, involving primary care and behavioral health providers et al. SBHC team

(2) Collaboration with school providers {nurse, counselor(s), social worker(s), psychologist(s), other providers}

(3) Coordination with Community Providers/Agencies

collaborating with schools
Collaborating with Schools
  • Throughout assessment and treatment
  • Team meetings -- vital process!!
  • Referral for Special Ed consideration initiates: -Review of school records -Educational Diagnostic Testing, eliciting further reports from school providers (directly) plus educators & administrators (indirectly)
team conference potential partners
TeamConference:Potential Partners

SBHC Medical & BH Providers Collaborate with:

  • School Nurse
  • School Counselor
  • School Psychologist
  • School Social Worker
  • Substance Abuse Counselor
  • Occupational, Physical, & Speech/Lang Therapists
  • Case Manager (if so fortunate!)
  • Educational Diagnostician
  • Educators: Teacher & Ed. Asst. {per case basis}
  • Administration {per case basis; often via above}
summary key messages
Summary: Key Messages
  • The mind-body interface presents clinically in many different ways, including headache, abdominal pain, backache, fatigue
  • Integrated medical and mental health care benefits students
    • Standard of Care for SBHCs
    • Allows us to assess and treat students comprehensively
      • Separation of Mind [“Psyche”] from Body [“Soma”], a contrived construct, limits care.
    • Compatible with the clinically useful BioPsychoSocial model
    • Preferred by school providers, educators, families, students
  • Psychiatric comorbidity, such as depression and anxiety, is common among students
  • SBHC teams best serve students by collaborating with school, school-based, and community providers.
resources tools websites
Resources: Tools & Websites

1) Standards and Benchmarks for SBHCs, Office of School & Adolescent Health (OSAH), New Mexico Dept of Health (NM-DOH) @ www.nmasbhc.org

2) Student Health Questionnaire (SHQ),OSAH, NM-DOH @www.nmasbhc.org

3)Modified PHQ-9 in Guidelines for Adolescent Depression in Primary Care (2007), pp.57;[email protected] http://glad-pc.org

4) Guidelines for the Management of Depression (“Depression Guidelines”),

New Mexico School-Based Health Center/Medicaid Program, @ http://www.hsd.state.nm.us/mad/HSchoolHealthDetail.html

(scroll to SBHC/MCO Project Clinical Guidelines: Identification and Management of Depression)

5) envisionnm.org  tools & resources

resources publications
Resources: Publications
  • American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR). American Psychiatric Press, Washington DC
  • American AcademyofChild & Adolescent Psychiatry (1997), Practice Parameters for the Psychiatric Assessment of Children and Adolescents. J Am Acad Child Adolesc Psychiatry 36(10):4S-20S
  • Engel G (1980), The Clinical Application of the Biopsychosocial Model. Am J Psychiatry 137:535
  • Kazura AN, Boris NW, Dalton R (2004), Psychosomatic Illness. In: Nelson’s Textbook of Pediatrics, 17th Edition, Behrman RE, Kliegman RM, Jenson HB, eds. Saunders, Chapter 19, pp. 72-73
  • Knight et al (2002), Validity of the CRAFFT Substance Screening Test among Adolescent Clinic Patients.Arch Pediatr Adolesc Med. 156(6):607-614
  • Martin A, Volkmar FR ed. (2007), Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. Lippincott Williams & Wilkins
publications cont
Publications, cont.
  • Waxmonsky J, Wood B, Stern T, et al. (2006), Association of Depressive Symptoms and Disease Activity in Children With Asthma: Methodological and Clinical Implications. J Am Acad Child Adolesc Psychiatry 45(8):945-954
  • Weist MD, Lever NA, Stephan SH (2004), The Future of Expanded School Mental Health. J School Health 74(6):191 {Identifies key strategy: “address special needs such as substance use problems, severe psychiatric disorders, violence-related issues, and co-occurring physical and mental health conditions”}
  • Weist MD, Goldstein A, Morris L, Bryant T (2003), Integrating Expanded School Mental Health Programs and School-Based Health Centers. Psychology in the Schools 40(3):297-308
  • Zametkin A, Zoon CK, Klein HW, Munson S(2004),Psychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years.J Am Acad Child Adolesc Psychiatry 43(2):134-150
acknowledgements
Acknowledgements
  • Your Participation—Thank you!!
  • Our colleagues with whom we integrate care
  • Anna Nelson LISW & Yolanda Cordova MSW et al. at OSAH
  • Paula LeSueur CFNP, Jane McGrath MD, Kris Carrillo LISW, Clancey Tarbox et al. at Envision New Mexico
  • Bob Kellner, MD, PhD and Lisa Forrest, MD
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