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May 25, 2013

By Julie Boman, MD, FAAP, pediatrician at Children’s Hospitals and Clinics of Minnesota

As pediatricians, we are well-versed in the rising rates of obesity among children over the past fifty years. Childhood obesity is theoretically a simple disease to treat: eat less, move more. But as most of us know, simple theories are often hard to put into practice when the underlying causes happen far from the exam room.

Statistics show that childhood obesity rates among certain minority groups are substantially higher than among white children. My practice at Children’s Hospitals and Clinics in Minneapolis has a high percentage of Latino children and we see obese children much too often. I saw an opportunity to do something slightly different than the usual office visit and follow up that I’d like to share with you.

In January of 2012 I asked the Minnesota Chapter of the American Academy of Pediatrics (MNAAP) to help me in applying for a small grant through the National Institute for Children’s Healthcare Quality (NICHQ) to reach out to local overweight/obese Latino children and their families. We were awarded a small start-up grant that gave us the seed money to get the ball rolling.

Our goal was to create a program that connected Latino families to people who could help them avoid — or reduce — obesity.  We wanted a program that got everyone involved — moms and dads and children — and we wanted to include community groups that had gained the trust of Latinos, such as CLUES (Comunidades Latinas Unidas en Servicio), the Waite House, the Minneapolis Park and Recreation Board, the University of Minnesota Extension Service and the YWCA.

The following summer we began spreading the word about this new program. We started our first classes with just a handful of people. Today these classes are overflowing with 80 people or more. Once a week families gather at a large meeting hall at the Waite House. They dance to Zumba; they create healthy meals and learn about real-world portion size; they measure and track their BMI; they discuss ways they can eat better and move more. If you were to visit one of these gatherings, you’d find it doesn’t look like a normal doctor’s office. It is a community based extension of the office visit.

So far, the early results are encouraging. More than 100 Latinos have gotten involved with Vida Sana on a regular basis.  Most of the adults and children have BMIs in the overweight or obese category, but many are seeing changes in their BMI in addition to changes in health habits.

Finally, and perhaps most importantly, we’re doing a better job of reaching a patient group that has been difficult to reach using traditional office visit  medicine.

By Joel V. Oberstar, MD, CEO and Chief Medical Officer at PraireCare

Many youngsters experience adverse childhood events and psychosocial stressors and seem to take it “all in stride.” Indeed, many clinicians who work with children on a regular basis find their resilience to be inspiring.

Some kids, however, find that adverse events and the stress of everyday life can become overwhelming. In those instances, accurate diagnosis and treatment of a mental illness is essential.

The top three most prevalent mental illnesses in children relate to anxiety, depression and disruptive behavior disorders. Adjustment disorders with disturbance of mood or conduct present in response to an identifiable stressor or stressors occurring within 3 months of the onset of the stressor. In these instances, the symptoms or behaviors are evidenced by either marked distress or significant impairment in functioning, but do not rise to the severity of another specific DSM-IV-TR Axis I disorder (e.g., generalized anxiety disorder, major depressive disorder, etc.).

Treatment of adjustment disorders frequently involves supportive psychotherapy—either individually for the child or for both the child and family—as well as psychosocial supports. A child who has experienced an acute stress related to bullying at school, for example, might respond well to individual cognitive behavioral therapy and social skills training to help him deal more effectively with his peers. Likewise, contacting the school counselor may provide an opportunity for adult intervention with the bully.

Should emotional and/or behavioral symptoms progress in severity, diagnosis of an Axis I disorder is appropriate and more aggressive treatment frequently indicated. In such instances, more aggressive psychotherapy may be paired with pharmacological interventions. For example, a teenage girl who suffers from major depressive disorder relating to parent-child conflict and parent-parent conflict in the home may benefit from interpersonal psychotherapy along with family psychotherapy. Consideration may be given to initiating a low dose antidepressant such as citalopram or sertraline.

In either instance, recognition of the emotional and/or behavioral symptoms is essential to facilitating intervention. All children have access to children’s mental health case management through their county of residence; parents may call themselves to receive support. Referral to any one of a number of psychotherapists for an initial diagnostic assessment is frequently the first step in receiving psychotherapy. Of course, the primary care clinician may elect to initiate pharmacotherapy. Such clinicians are encouraged to utilize the newly established Minnesota Collaborative Psychiatric Consultation Service (referenced elsewhere in the newsletter) for diagnostic and therapeutic support. Referral to a child and adolescent psychiatrist is less commonly indicated but may certainly be appropriate in certain instances.

By Peter S. Jensen, MD, Vice Chair for Research, Department of Psychiatry and Psychology, Mayo Clinic

The Minnesota Collaborative Psychiatric Consultation Service has been in place since August 1, 2012. On April 1, Allina Health joined Mayo Clinic, PrairieCare, Sanford Health, and Essentia. Together, the partners’ child and adolescent psychiatrists and triage mental health professionals are available from 7 am to 7 pm, Monday through Friday, for primary care and psychiatric providers seeking consultation for their most complex patients.

Service categories and specifics include (but are not limited to):

1. Outreach and education enabling collaborative partnerships between mental health and primary care, specifically training and CME for local practitioners to create a cadre of primary care “champions” providing quality mental health services in primary care and ongoing coordination with other collaborative efforts, such as medical homes.

2. Daily psychiatric consultation services to primary care and other health providers using evidence-based, state-approved protocols

3. Claims authorization and consultation procedure codes. Consultees can now code for their participation in the consultation. Claims can be submitted by both primary care providers and psychiatric consultants using the 99499 procedural code and can submit claims online. Providers may bill for a same-day office visit and a consultation when appropriate (see

4. Tools for locating available mental health services, namely Fast-Tracker, an online searchable database of mental health referral resources across Minnesota that provides region-by-region information about available mental health services and is accessible by mental health providers, primary care staff, and/or patients and families.

Data collected through March 19 shows that of the 396 consultations that have taken place, most were mandatory, resulting from prescriptions exceeding medication thresholds determined by the DHS Medication Threshold Workgroup made up of experts in child and adolescent psychiatry.

Consultations were for very complex cases with nearly 40 percent involving ASD Diagnosis. Of the 127 providers who had contact with the service, 88

(69.3 percent) were psychiatric specialists (MDs, CNS/CNP), 29 (22.8

percent) specialized in pediatrics (e.g., pediatricians, developmental and behavioral pediatricians, and pediatric CNS/CNP), 7 (5.5 percent) were family physicians and nurses, and 3 (2.4 percent) were neurologists.

The service also offers education and referral support through the coalition’s nonclinical partners, REACH and the Minnesota Mental Health Community Foundation. REACH has trained 65 to date with openings for 160 more through June 2015.

Trainings are scheduled in Duluth May 10-12, Rochester August 9-11, Moorhead September 20-22, and the Twin Cities October 11-13. The 2-day trainings (Friday 1 pm – Sunday 1 pm) offer a highly interactive training format to train champions for children’s mental health in their clinics. Trainees also benefit from six months of semi-monthly follow-up calls for case discussions. These trainings are integral to one of the service’s goals – building a stronger, more integrated network of providers in every region.

Fast-Tracker, a single source for providers and those seeking services, is available at Call 1-855-431-6468 to access the Minnesota Collaborative Psychiatric Consultation Service.

By Pamela K. Gonzalez, MD MS, FAAP, Diplomate ABAM, pediatrician and addiction medicine specialist at Abound Health LLC, adjunct assistant professor at the University of Minnesota and a member of AAP’s Committee on Substance Abuse.

While tobacco, alcohol and marijuana remain the most used and abused substances among adolescents, non-medical use (NMU) of prescription medications remains a serious problem. Reports on NMU, often dubbed “prescription drug abuse,” frequently focus on opioids. This may be due in part to relative greater overall use prevalence and overdose burden.

However, NMU of prescription psychostimulants by adolescents is quite prevalent, especially among US college students. The lay press often refer to these medications as ”study drugs”; a characterization that may minimize potential negative consequences, and miss the nuances of individual motivations for use, and the associated risks.

Before discussing prescription stimulant NMU, it is important to clarify some definitions. NMU may lead to, but is not the same as substance abuse or addiction. NMU generally involves taking a medication for which one does not have a prescription and/or taking one’s prescribed medication in a way other than prescribed (e.g., extra doses, increasing dose on one’s own, etc.) Many can suffer negative consequences from NMU, while their symptoms and behavior may be sub-threshold for a formal substance use disorder diagnosis.

According to Monitoring the Future, prescription amphetamine NMU has trended up since 2009, to current 12 percent by 12th graders. Use is more prevalent among college students, as illustrated by the College Life Study, where nearly two-thirds endorse being offered prescription stimulants by year 4, and just below one-third endorse trying them at least once. Almost 75 percent report the drug they used came from a student with a legal prescription. Other sources suggest that at least 1 in 7 youth receiving prescription stimulants for ADHD endorse diverting their medication.

Why are college kids taking these? A majority endorses academic pressure, needing a competitive edge, and enhanced focus provided by NMU. In fact, prescription stimulant NMU correlates with lower GPA, more class skipping, excessive alcohol use and other drug use, and more complaints of emotional distress and depressed mood. Non-medical users also endorse lower perceived harmfulness.

What is the harm? Common complaints include appetite suppression and sleep disruption. Potentially deadly complications can include hyperthermia, arrhythmia, MI, or stroke. Non-medical users frequently combine with alcohol or other drugs, contributing to drug interactions, unintended overdosage, and development of abuse or addiction. At its psychiatric extremes, some may experience psychotic symptoms (e.g., hallucinations, paranoid delusion) or become acutely suicidal, either during acute dysphoria of intoxication or post-intoxication “crash” when acute depression may ensue. Long-term effects of stimulant NMU remain unknown.

What can pediatricians do? First, ensure the accuracy of an ADHD diagnosis. Shockingly, only about one-quarter of physicians use all recommended components for establishing ADHD diagnosis. Develop a mental health provider network with which you feel comfortable collaborating and referring. This network ideally includes providers with expertise in youth substance abuse. If you are unsure of the ADHD diagnosis or management, refer to an appropriate specialist in your mental health network and/or utilize the Minnesota Collaborative Psychiatric Consultation Service.

Second, advise patients and caregivers against using prescription stimulants as academic enhancers, and educate them about the realities and pitfalls. In patients with established ADHD who are prescribed psychostimulants, reinforce the importance of never sharing or otherwise diverting medication.

Finally, screen for substance use problems at every adolescent encounter, including ADHD follow-up visits, according to the AAP recommended Screening, Brief Intervention and Referral to Treatment framework. Motivational Interviewing is an excellent approach to delivering such brief interventions.


By Tom Scott, MD, FAAP, Interim Director, Developmental-Behavioral Pediatrics Residency Program, University of Minnesota

The care of all infants, children and adolescents involves Developmental-Behavioral Pediatrics (DBP), whether by primary pediatricians or DBP specialists. Composing a relatively new sub-specialty, DB pediatricians provide care for a range of patients with developmental, learning, emotional, and behavioral disorders. Similar to primary care pediatricians, DB pediatricians also focus on healthy child and adolescent development, identifying strengths, promoting resilience, and reducing risk.

DB pediatricians work as individual consultants or in teams. Team members from other disciplines may be on site or in the community and include speech and language pathologists, audiologists, psychologists, nurses, education specialists, occupational therapists, physical therapists, nutritionists, neurologists, geneticists, and child psychiatrists. Sometimes primary care pediatricians consult directly with these other team members.

Whether a patient should be referred to a DB pediatrician, a child psychologist, or child psychiatrist and whether to an individual consultant or to a team depends on the nature and complexity of the problem and availability of specialty resources. Sometimes a referral to a person on the team will result in a recommendation for additional assessment by other team members. There may be overlap in the clinical expertise of specialists on the team, and in complex cases, additional perspectives may be particularly helpful diagnostically. DB pediatricians in Minnesota have varying areas of specialization, including autism, early childhood issues, ADHD, learning disorders, Down’s syndrome, sleep, self-regulation, and hypnosis. Also, some general pediatricians have special interests in DBP and serve as resources for other clinicians.

The following are general guidelines in making referral and consultation requests to DB pediatricians, child psychologists, and child psychiatrists:

Referral/consult request to Developmental-Behavioral pediatrician:
– Complicated school learning,attention, and behavior problems
– Questions of autism spectrum diagnosis and management
– Anxiety and depression
– Persistent somatic symptoms
– Persistent elimination and soiling problems
– Sleep issues

Referral/consult request to child psychologist:
– Questions of co-morbidity with learning and attention problems
– Questions of cognitive status
– Differential diagnosis of anxiety, depression, behavioral issues
– Questions of autism spectrum diagnosis and management
– Individual or family therapy
– Cognitive behavioral therapy

Referral/consult request to child psychiatrist:
– Out of control behavior
– Suicidal issues
– Questions of bi-polar disorder
– Questions of psychosis

Pediatricians in Minnesota, like those throughout the country, have concerns about the availability of DB pediatricians and long waiting lists. At present, almost all DB pediatricians in Minnesota are located in the metro area. A recent study found 86 percent of primary care pediatricians in the United States reporting too few DB pediatricians and 95 percent reporting too few child/adolescent psychiatrists to meet the needs of patients in their practices. In 2011 only 35 first-year DBP fellows were in training in the United States.

In order to address the shortage of DB pediatricians, advocacy at a federal, state and local level is essential.

The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, Third Edition, Marilyn Augustyn, Barry Zuckerman, Elizabeth B. Caronna, editors, 2011.
Encounters with Children, Pediatric Behavior and Development, Fourth Edition, Suzanne D. Dixon and Martin T. Stein, 2006
Primary Care Pediatricians’ Satisfaction with Subspecialty Care, Perceived Supply, and Barriers to Care, Journal of Pediatrics, 2011, Vol. 156, No. 6,1011-1015

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