The 11 “action signs” are written in everyday English instead of medical jargon — for example, if a child experiences “sudden overwhelming fear for no reason, sometimes with a racing heart or fast breathing.”

The list is endorsed by the U.S. Surgeon General, the American Academy of Pediatrics, the National Alliance on Mental Illness and other groups.

“The child mental health field needed something like what cancer had done” with its seven warning signs for the disease, said Dr. Peter Jensen, a Mayo Clinic psychiatrist who led the creation of the action list. “It needed some kind of crisp, easily understood messages that parents, teachers, health care providers could … relate to.” The list seeks to help parents differentiate normal childhood moodiness from abnormal levels of aggression, depression and hyperactivity.

Here are the 11 warning signs parents should watch for:

• Feeling very sad or withdrawn for two or more weeks
• Seriously trying to harm or kill yourself, or making plans to do so
• Sudden overwhelming fear for no reason, sometimes with a racing heart or fast breathing
• Involved in multiple fights, using a weapon, or wanting badly to hurt others
• Severe, out-of-control behavior that can hurt yourself or others
• Not eating, throwing up or using laxatives to make yourself lose weight
• Intensive worries or fears that get in the way of daily activities
• Extreme difficulty in concentrating or staying still that puts you in physical danger or causes school failure
• Repeated use of drugs or alcohol
• Severe mood swings that cause problems in relationships
• Drastic changes in your behavior or personality

Confusion by parents and doctors is one reason why as many as half of children with serious mental disorders are untreated, according to estimates by the U.S. Surgeon General, and also why some healthy children are misdiagnosed with disorders they don’t have.

“We needed to do something to help flesh out people’s understanding about what it meant when a child really did have a problem,” said Gary Blau, a clinical psychologist with the U.S. Substance Abuse and Mental Health Services Administration. “It’s different than just being a phase of sort of the traditional ups and downs of growing up. There is a difference between that and having a significant mental health problem.”

The difference often is when behaviors last for a prolonged period of time or affect other people. “Feeling very sad or withdrawn” isn’t enough, unless it has persisted for at least two weeks. “Severe mood swings” alone aren’t a warning sign on the list unless they “cause problems in relationships.”

The list was tested against children with diagnosed mental disorders to see if it would accurately forecast their conditions. A resulting study found that many of these children wouldn’t be detected by the symptom list. On the other hand, the study found that the list wouldn’t mistakenly identify children whose behaviors were normal pangs of growing up.

“As we wrestled with that, we realized there would be a potential for confusion or even harm if parents were worried when they didn’t need to be worried,” Jensen said. “And so what we did was we erred on the side of making sure that this child really has a problem” if he meets any of the action list criteria.

A report in the journal Pediatrics lists the action signs and the science and psychology behind them. Jensen said the word suicide was replaced with “seriously trying to harm or kill yourself, or making plans to do so,” because parents didn’t necessarily identify the term with children.

The list will make it easier for parents to decide whether to seek help for their children, Jensen said, because they only need to answer “yes or no” to the action signs. They don’t need to evaluate whether their kids meet complex diagnostic criteria for mental disorders.

“If you have five or six or seven things to weigh, decisions are very difficult, but if you have a simple yes-no decision, it becomes much easier,” Jensen said. “That’s what the Cancer Institute did when they created warning signs like 20 pounds of unexplained weight loss” as a predictor of cancer.

Out of 15 authors of the report, Jensen and one other researcher reported financial relationships that could present conflicts of interest. Jensen has been a paid consultant for drugmakers Shire and Janssen-Ortho. While the list could certainly hasten the rate at which children receive psychiatric medication, Jensen said it was not developed with any corporate interests in mind.

Advocates for three national patient organizations spoke in favor of the action list. They said they hope it would make it easier for teachers and doctors to believe parents when they express concerns, and for troubled children to receive faster treatment.

“Children may go as long as 10 years without intervention,” said Ruth Hughes, the chief executive for CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder). “Just think about what that timeframe is in a child’s life.”

Article sources:

The “Action Signs” Project – Mayo Clinic Research Institute

http://www.startribune.com/lifestyle/wellness/132788583.html,

http://www.childrenhealthwizard.com/mayo-clinic-lists-warning-signs-to-help-diagnose-children-with-mental-disorders

Other therapy and case management appointments are more flexible as far as time. All therapists, case managers, and wraparound facilitators work some evening hours so they can accommodate family needs for after-school and after-work times.

Speak with the therapist or case manager and let them know of your need for an after-school or after-work time appointment. You may also be able to work out an early morning before-school appointment. You may not be able to have all of your appointments at those times, but the therapist can work with you on a schedule to have some of your appointments outside of school time.

If you have difficulty scheduling according to your needs, you may also ask to speak with the customer service department which can help address this. The Northern Lakes CMH Customer Services representatives may be reached by calling 1-800-337-8598.

Sometimes the parent and psychiatrist do not come to a decision on that visit, but rather the psychiatrist sends additional information home with the parent to consider and they schedule a follow-up visit where the parent will relate their decision.

The psychiatrist will talk with the parent about the risks with the medication, as well as the risk in not using medication. Ultimately it is the parent’s decision. If the parent decides not to have the child receive medication, further appointments with the psychiatrist will not be scheduled.

Some children are seen by the psychiatrist once or twice, but are not prescribed medication. Some children are prescribed medication for a short period of time, but are not on medication on a continuing basis. Other children will be prescribed medication that will continue for a longer period. In the situation where the child is on a medication and it is working well, the psychiatrist, nurse and therapist/case manager will work with the family and the family doctor to transition the child back to the family care doctor for the medication management. The child and adolescent psychiatrist remains available to the family doctor for consultation if there are questions or concerns. Also, if requested by the family doctor, the psychiatrist will do an evaluation every year to look at the medication and offer recommendations to the family doctor.

If there is a crisis and you believe it is both a medical and mental health crisis, seek immediate medical care. This can be done with your primary care physician, a walk-in or urgent care clinic or hospital, depending on your assessment of the seriousness of the medical situation.

Who do I contact?
If your child is in mental health treatment, contact your service provider.  Clearly state that you believe your child is in a crisis. If you cannot speak to the service provider directly, leave a message saying you have a crisis situation and give the date, time and number where you can be reached. At the same time, follow any emergency contact instructions that are given, for example calling an “on-call” number, pressing “0” for the operator, or contacting a designated “after hours” crisis response number.  If you do not have an opportunity to speak to someone directly, and you have a “main number” for the organization, contact that number and tell them you have a crisis and need to speak to a service provider and do not want to leave a voice mail message.

In a crisis it is helpful to be able to work with the service provider with whom you already have a treatment relationship and who will be most able to address the situation considering what he or she already knows about the resources and challenges your child and family experience. Because crises are not planned, directly reaching your treatment provider may be difficult due to schedule conflicts, time off and illness and after-hours and weekend/holiday contact needs. Organizations handle this differently.  Some rotate an after-hours on-call crisis response,  some have a crisis phone number that responds to the initial call and then links a provider to the person in need, service providers are “on-call” for the persons they serve.

What is the protocol for a crisis assessment through Community Mental Health (CMH)?
At a CMH, you should expect to speak to someone within 60 minutes of the time you call.  A face-to-face crisis assessment can occur at the location where the crisis is occurring; for example, at the school, the home, or other community site, as well as at the hospital or a detention site.  The parent or legal guardian needs to be present for the crisis assessment.

The crisis assessment will examine the current condition of the child, the recent events for the child and family, and the immediate situation with the family and in the living environment.  The assessment may or may not include assessment for inpatient hospitalization. During the assessment, the mental health provider may consult with others involved in the child’s life or in their treatment; for example, a child’s relative who sometimes provides child care, the child’s physician or psychiatrist, or the mental health supervisor.

The person providing the assessment will give a recommendation to the parent or guardian. This could range from:

• remaining in the home with a follow-up safety plan,
• going to an extended family member who will provide the supervision and support needed for a brief period,
• having formal crisis respite for one to three nights,
• recommending the child have an inpatient psychiatric hospitalization.

If the child will remain in the home, a home of extended family, or have a crisis respite option, the mental health provider will develop a safety plan with the family and/or the respite provider.

If the results of the assessment indicate a need for hospitalization and the child has commercial insurance, the mental health provider will share the results with the parent/guardian and the insurance provider. The insurance provider will make the determination as to whether hospitalization is “authorized.” The mental health assessor will also provide information on availability of beds at various locations.

If the results of the assessment indicate a need for hospitalization and the child has public insurance, the mental health service provider will locate the nearest child/adolescent hospital with an available bed, while still considering family choice.  The mental health provider will also work with the family to explain the admission procedure, as well as providing support and assistance as the family arranges transportation.  The mental health assessor prepares the documents needed for the hospitalization.

If the recommendation is for crisis respite, the mental health assessor works with the parent in preparing the crisis respite materials packet, communicates with the respite provider agency and the respite provider about the plan of service related to the child and how situations are to be handled in the respite location during the brief respite period.  They provide support and assistance as the family arranges transportation to the respite site.

The person providing the mental health assessment will communicate with the doctors and other mental health treatment providers about the crisis assessment so that follow-up can be provided on the next business day.  Respite providers will have information as to contact resources if there are difficulties during the respite stay.

If the child remains in the family home, the family is instructed as to contacting CMH if there is a further need for crisis services.  The family is also instructed to call their mental health provider the next day to set up an “aftercare” appointment as follow-up to the crisis situation.  In most situations this face-to-face appointment would occur on the next business day.

If the child has not been receiving mental health services at the CMH, the person doing the crisis assessment assists the parent with contact numbers to set up an appointment to begin the assessment and treatment process.  CMH crisis services remain the point of contact until the initial assessment with a treatment provider.

Where do you go or who do you talk to if you are not satisfied with the results?
If you are not satisfied with the results of a crisis assessment the parent or guardian may request a second opinion.  They may also contact  Northern Lakes Customer Services at  1-800-337-8598 or 231-775-3463.  The mental health assessor provides information on obtaining a second opinion and accessing Customer Services.

Some children are referred for child psychiatry, according to standards of medical necessity. If your therapist is recommending a referral for psychiatry, please be sure to discuss in advance with the therapist your feelings about medication for your child. If referred for psychiatry, your child may or may not be prescribed medication.

When you call

When you call you will speak to a mental health professional trained to gather mental health screening information. You will be asked some questions about your concerns for your child, the kinds of symptoms or behavior you see from your child, and how serious or urgent the conditions are. This is to determine if it is an emergency where the child is at immediate risk of harm to himself or herself, or a risk to others. If it is determined to be an emergency, the child is seen immediately. If it is not an emergency, the child will be scheduled for an evaluation within 14 days. If it is not an emergency, but also not something that can wait two weeks, please be sure to share that with the screener.

What you will be asked

You will be asked identifying questions about name, address, age, name of school and grade placement, your child’s doctor, and any other treatment your child has received. You will also be asked questions about other “systems” with whom you may be involved, such as Special Education, Department of Human Services, the Health Department or Children’s Special Health Services, or Family Court. If there are any particular legal arrangements involving your child, such as custody or guardianship arrangements, you will be asked to bring a copy of those legal documents to the initial evaluation. You will be asked to bring any other documents that will aid in the evaluation. For example, if the child is having school difficulties, a report from the school is helpful. You will also be asked insurance information.

Appointments – what to expect

You will be given an appointment for your child and yourself. It very important that you accompany your child to treatment appointments. This is for the child’s sense of safety and trust, and to ensure that the evaluator is able to gather the needed information on the present situation as well as the history of the child and family. It is also necessary that the person who has the legal authority to consent to services attend the appointment. If the child lives in a two-parent family, it is ideal if both parents can attend the evaluation.

You can expect the initial evaluation to take about 2 hours. You and the child are first seen by a person who completes registration, provides you with information about services and your rights as a consumer receiving services, and obtains authorization to exchange information with those involved in the care of your child, such as the doctor and school.

After this registration, you and your child are seen by a therapist, called a Child Mental Health Professional, who will do the mental health evaluation. They will spend time with all of you together, but often spend some time alone with the child during the evaluation process. They will ask many questions about the current concern, the family’s background, the child’s development and general health, school performance and social relationships. They will ask questions about the child’s behavior, thinking and moods. They will use all of this information to determine the child’s level of functioning and to make what we call a diagnosis. This diagnosis, along with the level of functioning, determines what types of treatment services are suited to the child’s condition. The therapist will share this conclusion with you and make plans with you and your child around the treatment recommendations. Follow-up treatment will occur within one or two weeks.

If the evaluation determines that your child does not have a mental health condition that requires community mental health services, the therapist will offer you information about other community resources that may assist you and your child.