Moving knowledge, not patients.

Putting more brains on a child’s case.

They’re not medical descriptions, but they encapsulate the approach of KSKidsMAP: Bringing an interdisciplinary team approach to helping Kansas primary care doctors and other clinicians deliver mental health care to children and adolescents.

“No child is in a bubble. Their interactions at school and with peers, their genetics, their family environment, their living conditions, all that plays into their mental health. By really thinking about each child in a holistic manner, I think we serve the children better,” said Kari Harris, M.D., a pediatrician on the team and associate professor at KU School of Medicine-Wichita, home to KSKidsMAP.

The need is evident, as 99 of 105 Kansas counties are short of mental health providers. That leaves primary care clinicians trying to fill a gap, especially in rural areas. Treating the children in their home communities for anxiety, depression, ADHD and other, often complex, disorders is both the ideal and, as a practical matter, the reality as mental health providers and centers in larger communities often have long waiting lists.

Three years into KSKidsMAP, members of the team are publishing a study in the Journal of Clinical Pediatrics detailing the types of treatment recommendations they’ve shared with doctors and other clinicians who have signed up for the free service. The study, “Expert Team in Your Back Pocket: Recommendations from a Pediatric Mental Health Access Program,” is expected to be published soon and covers 49 patient cases from 2020 that involved 273 recommendations. By studying and quantifying their work, Harris said, the team can help ensure what they are doing is relevant to clinicians.

Besides Harris, the team consists of Rachel Brown, MBBS, a child and adolescent psychiatrist and chair of the Department of Psychiatry & Behavioral Sciences; Susanna Ciccolari Micaldi, M.D., assistant professor and child and adolescent psychiatrist; Cassie Karlsson, M.D., associate professor and child and adolescent psychiatrist; Nicole Klaus, Ph.D., ABPP, associate professor and child and adolescent psychologist; and social worker Polly Freeman, LBSW MSW, who receives consultation requests and connects clinicians with a long list of resources.

Their study’s recommendations on patient care include a range of themes, in order of prevalence: Psychotherapy, a thorough diagnostic evaluation (including re-evaluation), accessing community resources for care and protection, use or adjustment of medications, resources and toolkits for patients and caregivers, and education.

Psychotherapy led the list, suggested in about a quarter of cases, but the recommendations are fairly dispersed across cases, with most involving multiple ones from the team.

“It really highlights their questions falling into these different categories involving medications, diagnosis, community resources and types of therapy approaches,” Klaus said.

The cases presented by primary care clinicians often require approaches beyond medication, which may be a doctor’s first question but once discussed, additional needs are identified.

“That reflects the complexity of cases these clinicians are taking on, just the challenges in managing multiple comorbidities and kids with more severe mental illness,” Klaus said.

So a patient and their parents might be given toolkits to manage behavior. Parents and caregivers might be encouraged to attend therapy sessions. Schools might be pushed to create individualized education plans to help a student struggling with ADHD or anxiety. A doctor might consult protective services if a patient is suffering possible neglect or abuse. Or a physician might get advice on starting a child on a psychotropic medication or tapering them off one.

“What is so beneficial about the team is you are putting multiple minds together to tackle a single case. So you're going to have more than just medication recommendations,” Harris said. “With input from this team, you walk away with a robust plan full of resources for that child and their family.”

“We did a case recently of a high school student on the brink of expulsion,” Harris recounted. “The presenting question was, ‘How do I manage the medication and decrease the dose?’ But what came out of the consult was a plan to try to preserve the child’s educational career.”

The study also demonstrates the importance of correctly identifying the problem at hand.

“The recommendations often go back to diagnostic clarity,” Harris said. “It emphasizes the importance of really having a clear diagnosis before you go into a treatment plan.”

“Diagnosing a child with any kind of psychiatric disorder takes time, which many primary care clinicians don't often have because they see many patients in a day,” Ciccolari Micaldi said. “Screening tools can help, but you need to go back and sit down with the child first, and then you bring in the parents and discuss the symptoms. We understand that time is a big problem.”

KSKidsMAP, a partnership of the Department of Pediatrics, Department of Psychiatry & Behavioral Sciences and the Kansas Department of Health & Environment, is funded by a four-year federal grant of $2.1 million. Going live in early 2020, it’s one of a number of similar programs across the country, though many don’t involve a team approach.

The virtual case consultations the team performs are just one facet of KSKidsMAP. It also has wellness resources for clinicians and a twice-monthly TeleECHO virtual clinic, which offers case presentations and didactics on topics such as screening and diagnosing mental illness and managing medications.

The new study on case consultations builds on an earlier one that looked at what questions clinicians asked the team (medication topped the list) and will be followed by another focusing, through clinician interviews, on how treatment went. The program has grown steadily and now has over 240 clinicians participating.

The team’s ability to provide detailed information and treatment steps is appreciated.

“Many clinicians found that very helpful, and it builds their confidence in talking with patients and families,” Ciccolari Micaldi said. “Many of them feel more comfortable discussing medications and suggesting therapy, now that they have help and support.”

“I'm just so grateful that we have these pediatricians and primary care clinicians who are willing to take on these really challenging cases,” Klaus said. “And I'm glad that we can be there to support them in providing high-quality care for those kids.”