Motivating Families to Address Mental Health Concerns

1. Motivating Families to Address Mental Health Concerns Eleanor Mackey, Ph.D. Gail Avent Lakeshia Lewis

2. Disclosures • No relevant disclosures. • No relevant conflicts of interest. • There will be no discussion of off-label use of medications.

3. Learning Objectives • To recognize barriers to following referrals for mental health services • To learn some Motivational Interviewing techniques to improve follow-through • To learn ways to educate families about mental health care

4. Overview • Barriers to following mental health recommendations • Use of brief education • Use of Motivational Interviewing • Patient Examples

5. Why is this relevant? • Pediatricians see many children with emotional and behavioral difficulties which impact their functioning • Mental and behavioral health services can deliver treatments that work • No-show rates for initial treatment sessions range from 48-62%! • How can pediatricians help families follow through?

6. Potential Barriers • Family feels judged • Concern “physical” problems not taken seriously • Misunderstand recommendation or purpose of referral/Do not understand what mental health services can do for them • Do not agree that this is a problem/May not want to believe their child has a mental health concern • May not want to “stigmatize” or label by seeing a mental health professional • May not believe in benefit of mental health services • Competing stressors/priorities • May have difficulty getting to or affording weekly therapy sessions

7. Example • Example of barriers from Lakeshia

8. Motivational Interviewing • The first step is to help the parent/child see how making a change (with the help of a professional) can improve their lives. • Motivational Interviewing a helpful tool • Quick • High Impact • Culturally sensitive

9. Example • Joe is a 7 year old boy who comes in reporting frequent stomachaches. It becomes clear that he is very fearful, has trouble sleeping on his own, is scared to go to school, and is having difficulty making friends. • Other relevant information is that he lives with a single mom with 3 other children. They do not own a car and financial resources are tight.

10. Start with Motivational Interviewing • Goal is for the family to identify that they believe life would be better for Joe to have less anxiety and feel motivated to treat it • Can get there by guiding them to identify that these behaviors could change and, if so, could improve life for Joe and his family

11. Questions to improve motivation • What are your hopes for Joe in terms of how he feels about going to school or separating from you or making friends? • How do you think Joe’s life would be different if these things were easier for him? • What are some of your goals for Joe? • Joe, if you woke up tomorrow and these things, like going to school or talking to other kids, didn’t bother you so much, what would it be like?

12. Questions, continued • Other questions to the child: • If you had a magic wand and could use it to make three wishes to change something about your life, what would they be? • If you woke up tomorrow and those things were changed, what would that be like for you?

13. Questions for the parent • I imagine it is not easy to manage getting to appointments with your job and childcare. You are here today, which is great – how were you able to manage it today? • Are there resources you have that help you for coming to see me that you could use to help get Joe to other appointments as well? • What do you need to support your efforts to help your child? • Goal is to help the parent feel like a partner and the most important team member in helping their child

14. Examples: Gail • My son was diagnosed with Oppositional Behavior Disorder at the age of 9 years old. I was very reluctant to believe my child was not normal. He had suffered trauma during a very difficult divorce. • After my son returned home, I began to notice lots of negative behavior in the home and school. I took him to Children’s for help after he cut superficial wounds on his wrist.

15. Examples • The pediatrician carefully listened as I explained my son’s behavioral history and gave me a referral to a therapist. It was very difficult to acknowledge my son had mental health issues. • The difference for me was when the pediatrician said to me, “I don’t know where this is going to lead you, (in terms of treatment) but stick with him because he is going to need you.” So, I did just that. I attended sessions with my son and began to read everything I could about his diagnoses and other mental health illnesses.

16. Examples • Over the years, I reflect back to the pediatrician’s statement and am glad I did not give up on my son. • For a lot of parents who learn that their child has mental health challenges, they (the parent) need to feel empowered with information and supported by professionals and others. • Parents can accept responsibility better when they believe that whatever the situation is about their child, it will be objectively viewed without blaming and shaming. Parents want to be partners to help you help their children.

17. Education • Second step is brief education • Once you have the family motivated that changes would be important, tell them how a mental health professional can help • Parent and child need to understand what a mental/behavioral specialist is and does and how this is relevant to their concerns

18. Follow-up Education Statements • Thoughts and feelings like the one Joe is having are not uncommon, but it sounds like they are making life difficult for him and you both would like for them to improve. • In addition to making sure that we understand his stomach pains and that we are managing those, it may be helpful for him to see a professional who has expertise in helping children with the worries Joe is having.

19. Follow up Education Statements • I would like to refer you to a specialist to help Joe. Would you be willing to try, since it sounds like both of you would like to see improvement? • Like coming to see any doctor, this specialist would get more information about when, where, and what happens. They will use well-known treatments to help him feel better by learning new skills and ways to manage his body’s response to worry.

20. Follow up statements • Behavioral health specialists usually see kids once a week for a few months. This allows them to truly teach kids how to use and practice new skills that can help. • Remember, that the brain is the most powerful part of the body and works like a muscle. A behavioral health specialist works like a coach and teaches you new skills and then helps you practice them so you can get good at them.

21. Follow up statements • As Joe’s parent, the therapist will also be able to help you learn ways to help Joe. He can practice during each appointment, but as his parent, you will be able to help him the most each day, so you will also be part of the process. You may find that these skills you learn help your other children too! • You will be the most important team member for your child. You know him/her best and are the one on the ground able to help in real world situations. A behavioral health specialist will be able to support you in this role as well.

22. Wrap up • At this point, provide some referrals. Make sure, if possible, to refer to places nearby the family and with convenient hours in order to reduce barriers to attendance. • Ask if the family has any questions or concerns. Be particularly aware of the fact that they might have questions about what caused this problem for their child. They may need you to be optimistic and realistic about likelihood of success in treatment. • Ask when they will call to set up an appointment. • Remind them that they may have to call a few places before they get an opening. • Always tell them that they have to feel comfortable with a provider, so if they start somewhere and after a few appointments don’t feel it is helpful, don’t give up, but try another resource on the list.

23. Summary • Keep in mind barriers family might be experiencing • Use motivational interviewing questions for a quick way to get families to buy into need for services • Once you have buy in, give some education about what mental health specialists do and why it is useful