Program offered to help children’s doctors understand mental health better

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Dr. Dana Crater, a pediatrician for MacKoul Pediatrics in Fort Myers gives advice to patients on Friday 4/20/2018. She has taken REACH training, which helps pediatricians in their diagnosis of mental and behavioral health issues among children.(Photo: Andrew West/The News-Press)Buy Photo

After meeting with Jessica Muench and her son, Nathan, for about an hour, Dr. Dana Crater told them she wished she could spend that amount of time with all her patients.

And she has a greater wish.

She’s on the front lines of a major problem in Southwest Florida: About 1 out of every 5 children 12 and under – or 40,000 – have some kind of behavioral or mental health issue. 

Attention deficit disorder. Bipolar. Autism. Depression. Anxiety. Nathan has attention deficit challenges. 

Crater wishes that all pediatricians, internists and family practitioners could go through REACH training to get a better grasp of children’s behavioral and mental health issues. She has gone through REACH, a six-month program where pediatricians work with specialists in child psychiatry, psychology and pediatrics.

Healthy Lee pushed for the program. The first two training sessions were funded by grants from the state and the Schulze Foundation to SalusCare. Training costs run from $65,000 to $75,000.

“It’s really needed,” Crater said. “We can’t send everyone to specialists. It can take kids months before they get an appointment.”

Adding to the problem: There aren’t enough psychiatrists and psychologists in Southwest Florida to treat those 40,000 children. Dr. Emad Salman, the regional medical officer for Golisano Children’s Hospital, said he’s not sure how many professionals there are but noted that many psychiatrists and psychologists take cash only because Medicaid reimbursements are low.

Dr. Emad Salman (Photo: Lee Health)

This five-county area ranks among the worst in the state in Medicaid reimbursements while Florida ranks 48th or 49th out of 50 states.

Armando Llechu, chief administrative officer, Golisano Children’s Services, said 74 percent of patients in this area are uninsured or are covered by Medicaid.

 “It’s our Mount Everest to conquer,” said Salman, who also is a hematologist and oncologist specializing in pediatrics. “In Fort Myers and Southwest Florida, we’ve been building mental-health partners. There’s no one solution to this, no one group that can come up with all the answers. We all have to have communication and form a partnership in forming mental health care. We have to state and address the issues.”

Nathan, 14, who has attention deficit challenges, had a great outlet – riding ATVs, dirt bikes and Jeeps with father, David Muench.

However, David Muench was injured 1½ years ago and needed to have his foot amputated. Nathan used his spare time playing his Playstation and using  his smartphone looking at social media. He hasn’t been as active and it affected him.

“Our life has been sitting down and not doing anything,” Nathan said. “I miss that but you have to do what the family does.”

Jessica Muench added, “That was their thing, the ATVs, the dirt bikes, the Jeeps and the mud parks. Then it completely stopped. Nathan had a hard time dealing with his emotions so we talked about it.”

With the help of his mom, aunts, uncles, cousins, Dr. Crater and a psychologist, Nathan said he feels he can be honest and express how he feels. He also mows the lawn, which makes him feel more grown up.

“I am able to say what I feel,” he said. “I feel I’m opening up and letting all my feelings run out and I don’t have to let it build up inside me.”

After David Muench received a prosthetic, he and Nathan have started to get active again. With a self-assessment of his challenges that many teens and men have trouble expressing, Nathan likes how he’s progressing.

So does mom.

“I think Nathan has grown quite a bit,” she said.

What is REACH training?

Founded by Dr. Peter Jensen, the Resource for Advancing Children’s Health (REACH) launched in July 2007 to improve children’s emotional and behavioral health.

Despite advances in the scientific knowledge of brain development, mental health problems and their treatments, Jensen saw that health care professionals didn’t effectively use this knowledge to diagnose and treat common childhood mental disorders.

Ironically, the REACH Institute also works within Golisano Children’s Hospital in Rochester, New York.

In 2016, REACH doctors worked with their first group of Southwest Florida pediatricians. By the time the second round of pediatricians finish this fall, 43 will have completed the program.

In March, training began on a Friday, Saturday and Sunday. There were interactive and case-based sessions with four instructors from around the country, which included psychiatrists and primary-care physicians.

Topics included ADD or ADHD, depression, anxiety, bipolar disorder and aggression, specifically screening, diagnosis and treatment. 

Scenarios were played out with the pediatricians asking questions of families, recognizing behavioral challenges, making a diagnosis, coming up with the right dosage on medications and managing side effects.

“It was pretty intense,” said Crater, who has been a pediatrician for almost 10 years with Mackoul Pediatrics Fort Myers. “They introduced us to screening tools, rating scales, and we learned details about medication management using a case-based approach. It was very interactive and super helpful. It teaches us how to better manage children in our primary-care physician setting.”

Treatment plans can be started much more quickly and effectively in a primary care setting, since it often takes patients months to get an appointment with a psychiatrist. 

“Patients’ diagnoses will be recognized sooner, we can begin treatment immediately, and through the conference calls, we have access to an expert’s opinion for the more difficult cases,” Dr. Crater said.

After the weekend training, pediatricians have a conference call every two weeks where they talk about their more difficult cases and seek input from other colleagues. Those conference calls will last almost six months.

Dr. Nathan Landefeld, who is in the middle of training, believes this will help pediatricians deal with the less complex cases and free psychiatrists to focus on the more difficult ones.

“We’ll be able to work with a higher percentage of patients without the help of a psychiatrist,” he said. “It’ll be more objective with more tools to use rather than ask about symptoms and make a diagnosis.”

Landefeld said lack of psychiatrists will continue to be a problem as long as reimbursement is low. He said pediatricians usually can pinpoint a diagnosis for a physical ailment a lot quicker than one dealing with the mind. He added psychiatrists could go broke if all they took was Medicaid cases; and that’s the coverage most families have.

“They don’t get reimbursed well because that care is not valued,” Landefeld said. “There’s a supply and demand and nobody gets paid a lot to do it. Government officials and other folks have the means to decide and they’ve decided it’s not a big medical problem.”

Meanwhile, 37 percent of students with mental health symptoms by age 14 drop out of school and 70 percent of youth in the state and local juvenile justice system have a mental health condition, according to the National Alliance on Mental Health.

Getting the word out

For the past 18 years, SanCap Cares has raised more than $15 million for children’s hospital programs in Lee County.

In April, the Sanibel and Captiva fundraisers brought in more than $750,000 for its Island Celebration. Dr. Salman said he’s waiting final confirmation but believes future REACH training costs will come this event.

“I had reservations on mental health with the stigmas,” said Diana Day, co-chair of the Island Celebration. “But the response was awesome. We had as many sponsorships or more than we ever have.”

Day said in a final Gift from the Heart, $220,000 was raised for mental health.

“People are taking it to heart,” she said. “I think raising awareness has been part of the solution.”

SanCap Cares fundraisers brought in more than $750,000 for its April Island Celebration. (Photo: SanCap Cares)

Dr. Salman said people having conversations about mental health and sharing their heartbreaking stories are making a huge impression.

“Best friends are saying, ‘My child has this issue’ or ‘I lost my child and I don’t want somebody to lose theirs and we need to do something,’ ” Salman said. “They’re not embarrassed.

“We’ve gotten out of the taboo box. We’re talking about it.”

Children’s behavioral health statistics

46,000: Southwest Florida youths between ages 0-17 who have a seriously debilitating mental disorder (20 percent of youth population).

It takes about 8-10 years from onset of symptoms to intervention, mainly because of misdiagnosis and lack of access

70 percent of youth in state and local juvenile justice system have a mental health condition.

50 percent of all lifetime cases of mental illness begin by age 14

37 percent of students with mental health symptoms by age 14 drop out of school

11 percent have a mood disorder

10 percent have a behavioral disorder

8 percent have an anxiety disorder

Sources: Centers of Disease Control and Prevention; National Alliance on Mental Health; National Institute of Mental Health

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Source: https://www.news-press.com/story/news/2018/04/30/reach-training-helps-pediatricians-better-understand-challenges-childrens-mental-and-behavioral-heal/526076002/

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