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Project TEACH/NYS AAP April 2020 Newsletter

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David Kaye, MD

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Project TEACH E-Newsletter

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Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.

One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2020 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.

And now to our topic of this Project TEACH Pediatric Newsletter:

Resources for Parents During COVID-19

By Amber Parden, M.D. and David Kaye, M.D.

PART 1: GENERAL RECOMMENDATIONS

In this unprecedented time of history, what guidance do we offer to the parents and caregivers of the children in our care? The first thing we all have to remember is, like in an emergency on an airplane, parents need to put the oxygen mask on themselves first, then their children.  One size will not fit all and nobody has a map so we all need to be flexible and do the best we can. Secondly, families need to create a routine that works for the unique needs of their family members, bearing in mind the wellbeing of the parents as well as the children. This routine planning will inevitably take some improvisational trial and error. Don’t be afraid to adjust as you learn what works and what doesn’t work for your family.
Pediatric Primary Care Providers in New York State have long enjoyed access to free phone consultation warm lines, remote telepsychiatry evaluations, and referral to community resources available through Project TEACH. Flexible, creative, collaborative approaches like telemedicine and psychiatric phone consultation can provide assistance to Pediatric Primary Care Providers to support the families in their care during the COVID-19 pandemic: https://projectteachny.org/covid/
General recommendations for parents:
  1. Convey a sense of safety. Questions of safety are big questions for children and adolescents, especially so for younger children. Reassuring kids that they are safe physically and emotionally, and that their parents and loved ones are safe is essential. This is why it is so important for parents to keep their own emotions in check as much as possible. Emotions can be contagious and creating a calm, safe environment starts with the adults. Although social distancing outside the family is paramount, hugging and touching does not need to stop inside the home. Physical contact between parents and children helps to maintain a safe and supportive environment.
  2. Maintain “good enough” child and family routines. Keep routines in place as much as possible and encourage healthy habits. This will contribute to a sense of safety. Good elements of a family routine include getting adequate sleep, eating regular meals together, and making time for exercise. A routine makes the day more predictable. This predictability is helpful for all kids, and crucial for younger or anxious children. Most children will have ongoing school responsibilities and time for these school activities should be scheduled and maintained. Creating written (or pictorial) schedules may be helpful for children and adolescents. Visual prompts, verbal reminders, and timers can be very useful for times of transition for those children who find this challenging.
  3. Get outside. Going outdoors is essential physically and emotionally for parents and children. This can be a good opportunity for talking and listening as well. Ideally children should get outside every day for at least 30 minutes. Indoor physical activity on rainy days can also be helpful.
  4. Sleep is crucial. Maintain regular bedtime routines and habits. For many children and families this will mean continuing to use the same bedtime as before, while other families may find it helpful to shift bedtimes and wake times to accommodate the needs of the entire family (e.g. to allow parents enough sleep). Total sleep time should remain the same and getting up should be about the same as during the regular school year. Flexibility on the timing for some (e.g. adolescents) may be appropriate but all with the understanding that everyone in the house needs as much (or more sleep) during the COVID crisis.
  5. Make “rest time” for kids and adults. Everyone needs down time and some of this should occur ideally during the day. Designating a time for this (e.g. 3-4 PM) will work for many families. This can also be a time to encourage children to occupy themselves and be more independent.
  6. Create opportunities for new shared activities. This time may be ripe for adding activities to the routine. If family dinners are not already a regular routine this is a great time to start. Family games, arts and crafts, cooking, baking, or yoga are great options to keep your child occupied. These activities can also limit the amount of screen time children are exposed to. Family time can be a time where children can plan for things that they can look forward to and shift their quarantine to a positive mindset while looking forward to new activities each day. Each family member may have a role to play to be sure one individual does not get overwhelmed.
  7. Limit the news for yourself and your children. Information overload is rampant and it is not advisable to keep the news on while children are in earshot as this can provoke anxiety in both parents and children. Social media is also a place requiring parental monitoring as there can be posts that feed anxiety with panic inducing or even false information. Using the provided resources below to control the narrative surrounding the pandemic and to explain what is going on in a developmentally appropriate way is useful so that children know what to expect, but do not expect the worst.
  8. Listen and talk with your children and adolescents. It is especially important during this crisis to remain engaged with your kids and to ask how they are feeling. The National Child Traumatic Stress Network has a helpful chart to identify how different aged children may react to overwhelming feelings amid this pandemic.  Project TEACH and the MGH Clay Center for Young Healthy Minds also have good guidance on approaching this with your children.
  9. Stay in touch. Keep in touch with friends, family and loved ones. Facetime, skype, and other similar video chatting apps may be the only way for children and adolescents to keep up with their friends. Staying in touch with grandparents and other extended family in some manner is crucial for children and families, and promotes a sense of safety and continuity.
Resources:

PART 2: RECOMMENDATIONS FOR PARENTS OF CHILDREN WITH DEVELOPMENTAL DISABILITIES AND/OR MENTAL HEALTH CONCERNS

For parents of children with developmental disabilities and/or mental health concerns, this time of sheltering at home presents additional challenges. One change that often follows treatment disruption is that patients return to their Pediatric Primary Care Provider to rebuild the care team and create an effective treatment plan. Project TEACH provides free phone consultation warm lines, remote telepsychiatry evaluations, and referral to community resources to assist Pediatric Primary Care Providers to assess and manage both new and well-known patients during the COVID-19 pandemic: https://projectteachny.org/contact-us/

Guidance for parents of children with common conditions is as follows:

For the Child with Developmental Disorder

These are extremely challenging times for families with children with Autism Spectrum Disorder or other developmental disorders. Routines are disrupted and the usual community supports and resources are less available and generally only accessible by phone or online. Finding new ways to establish routines and permitting parents to have “rest times” is essential. Support is available through the Office of People with Developmental Disabilities (OPWDD) and parents should stay in close touch with their care coordinators and mental health providers that they are already linked with. Tips for parents include:

  • Have an emergency plan in place outlining provisions for childcare if a primary caregiver is hospitalized or otherwise ill or quarantined.
  • Develop a daily schedule for the child. Contact the child’s teacher and obtain the school schedule to incorporate into the family daily routine. The familiarity of elements of the school schedule may help the child to adjust. Parents may need to make adjustments based on the child’s response as well as their own needs.
  • Use visual prompts to maintain routines. Again contact the school teacher to obtain any successful visual prompts they have already developed.
  • Incorporate physical breaks at regular intervals.
  • Include the child in joint activities as they are able (e.g. cooking, cleaning chores).
  • Be flexible about screen time. Allowing for more screen time than usual is going to happen for many, if not most, families. At the same time be cautious about allowing too much time on screens and developing habits that will be difficult to change later.
  • Telehealth appointments with pediatricians are strongly encouraged. These appointments allow for ongoing monitoring and promote a sense of continuity and stability for developmentally disabled children and adolescents. Because telehealth appointments are generally well accepted by children and much easier on the adults who need to transition and transport the child to the doctor’s office, this modality may become the standard for many appointments with developmentally disabled children after the COVID crisis resolves.
  • Set up reminders to refill medications and maintain regular schedules of medication administration.  A discussion with the pediatrician about troubleshooting the details of medication adherence and management can be very helpful in finding practical solutions to these issues.

For the Child with ADHD

The difficulties for the child with ADHD are more focused on maintaining structure for the child and minimizing negative social interactions with other family members prompted by difficult behaviors.
  • Maintain usual school routines and schedules.
  • Utilize behavioral approaches successful at school (these can be obtained by contacting child’s school).
  • Stay in touch with your pediatrician; this is a great time for telehealth appointments.
  • Continue the same medication regimen your child has been using unless discussed otherwise with your pediatrician.
  • Incorporate lots of physical breaks into the daily routine.
  • Maintain sleep routines; although flexibility is important in many domains now is not the time for flexibility on sleep for kids with ADHD! Parents need to have time to recharge their batteries and if children stay up too late parents don’t get this opportunity.
  • Project TEACH offers parents and families advice for children with ADHD: https://projectteachny.org//srv/users/serverpilot/apps/project-teach/project-teach/web/app/uploads/2019/06/ADHD.pdf

For the Child with Anxiety/Depression

  • Stay engaged with your child.
  • Encourage active engagement with productive activities (school, homework, physical activity, hobbies, chores, etc).
  • Minimize isolation and check in frequently enough with the child that they know the parent is engaged and paying attention, but not so much that the parent is seen as “bugging” their child.
  • Maintain sleep routines used during the regular school year.
  • Ensure the child is engaged in outdoor activities at least once per day.
  • For teens, monitor alcohol in the home .
  • Stay in touch with your child’s emotional pulse by asking and listening to how they are feeling each day. It’s more important that a child feel listened to than that the parent came up with the “right thing to say.”
  • For anxious children, as always, encourage children to face their fears and avoid colluding with the child’s anxiety by making excessive accommodations. Because so many activities are restricted by the current crisis anxieties may manifest themselves in more subtle ways. Parents need to continue to challenge their children to “build their emotional muscles,” better tolerate their anxiety, and maintain their freedom to live their life fully.
  • For depressed youth, parents should be monitoring for any signs of impulses for self-harm or suicide. Crisis services remain available in all counties. Mental health providers are available by phone or telehealth for new evaluations or ongoing treatment.
  • If already linked for mental health treatment, parents should stay in close touch with the child’s mental health professionals.
  • During the COVID pandemic, pediatricians should continue to monitor and provide support for the children in their practice with anxiety/depression. This may be an easier time to stay in touch with mental health professionals providing psychotherapy. A conversation between the pediatrician and mental health professional can be enormously helpful for all.
  • Project TEACH offers parents and families advice on what to look for in children experiencing anxiety: https://projectteachny.org//srv/users/serverpilot/apps/project-teach/project-teach/web/app/uploads/2019/06/Anxiety.pdf
  • Project TEACH also offers parents and families advice on what to look for in children experiencing depression: https://projectteachny.org//srv/users/serverpilot/apps/project-teach/project-teach/web/app/uploads/2019/06/Depression.pdf
Resources:

Overview of Project TEACH Services

Current initiatives in Medicaid and Commercial insurance and the NYS PCMH incentive project, all create an environment that encourages pediatric practices to work toward integrating children’s behavioral healthcare into pediatric primary care. Behavioral health integration has the potential to enhance the value proposition for most practices.
Project TEACH Child and Adolescent Psychiatrists are available through the Project TEACH warm lines to provide guidance on assessment of a children’s and adolescents’ mental health symptoms and evidence-based treatment following traumatic events. You can also find the Child PTSD Symptom Scale (CPSS) on the Project TEACH website: https://projectteachny.org/rating-scales/
Project TEACH direct services to pediatricians include:

Accessing the educational and supportive services of Project TEACH can help your practice contract for higher payments, while also supporting you and your team in providing more comprehensive higher quality care to your patients with mild-to-moderate mental health concerns.

About The Author

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David Kaye, MD
David L. Kaye, M.D. is a child/adolescent psychiatrist and Professor of Psychiatry at the University at Buffalo (UB) Jacobs School of Medicine and Biomedical Sciences. Dr. Kaye received his medical degree from the University of Vermont in 1977 and subsequently completed his residency training in general and child/adolescent psychiatry at the University of Wisconsin. He has been on the faculty at the University at Buffalo since 1982, established the residency training program in child/adolescent psychiatry in 1991, and remained the Director of Training until 2014. Since 2010 he has been the Medical Director for the child psychiatry access program Project TEACH and in 2022 became Executive Director. The program received the APA Psychiatric Services Bronze Medal in 2016-17 and the Rieger Service Program Award for Excellence from AACAP. He has served in many positions of leadership regionally, nationally, in the medical school, hospitals, and department of psychiatry at UB. Dr. Kaye has published papers and chapters on a variety of topics, including education, collaboration with primary care, and psychodynamic psychotherapy in children and adolescents. He is the first author on a book for primary care providers entitled Child and Adolescent Mental Health (Lippincott Williams and Wilkins 2002). He has presented frequently at national meetings and has been a leader in national organizations, including the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Association of Directors of Psychiatric Residency Training (AADPRT), serving as President in 2009-10. He has received two of AACAP’s highest awards as recipient of the Catchers in the Rye award in 2016 and the Simon Wile MD Leadership in Consultation Award in 2021. He is a Distinguished Fellow of both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

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