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The Symposium was a multi-disciplinary event including the orthopedic physicians and surgeons and their PAs, the sports physical therapists, and the athletic trainers from Seattle Children's Hospital. In my almost 2 years working at Seattle Children's, it has historically been a rare occurrence for all of these providers to be in one place at the same time - but we're treating the same conditions and working together on so many patients, that it was neat to have this opportunity.
There were two speakers at the event discussing various topics from mental health. First, Dr. Cora Breuner, a physician at Seattle Children's and a professor at the University of Washington with expertise in pediatrics, adolescent medicine, orthopedics, and sports medicine discussed some of the critical components of evaluating patients with consideration for finding mental health or substance abuse red flags. She was listed as one of Seattle's best doctors in 2018 (and several previous years!) by Seattle Magazine, and her presentation was engaging, informative, and entertaining.
From her presentation, I learned two new acronyms to include in my evaluations which I previously had only included small parts of, but now have better understanding for the importance of going into more detail. These are mental health screening tools meant for the adolescent population and which fit into the biopsychosocial model of care nicely. The acronyms: HEEADSSS and CRAFFT examine the adolescent's personal life while CRAFFT is a screening tool for substance-related risks such as drugs or alcohol that fits into the HEEAADSSS assessment.
HEEADSSS breaks down into: Home, Education, Eating, Activities, Drugs, Suicidality, Sex, and Safety. There are a few different versions when I searched for better understanding of this acronym - where some of the dual letters are combined into groups. Let's look at these in a little bit of detail. Every time I sit down with a patient, and usually they have a parent with them, my first job is to make them comfortable and try to connect with them. If I'm going to treat you and help you manage your pain, there's a chance I'll need to touch you or have you move your body in ways that are new to you - so I need to earn the kid's trust.
Ever try to make friends in Seattle as an adult? It's hard! Want to make friends with a teenager in less than 5 minutes? Find out what they like and make sure they know you're talking to them - rather than their parent - and you might have hope! Fortunately I have a wide array of interests and background- so I can talk a little bit of sports, a little bit about music, a little bit about Harry Potter, a little bit of Disney Movies, and a little bit of "I also went to high school once so I can relate to your hatred for Spanish Class" to try to connect with these teenagers! I always ask components of the HEEADSSS assessment because it's an easy way to break the ice with a kid. Here's some of what I already would typically ask: Home: Who brought you to the appointment? Who do you live with? Do you have any pets? Are you nice to their little brother or sister? Education: What grade are you in and what school do you attend? Do you have friends? What are your favorite classes? Activities: What do you do for fun? Any sports, musical instruments, clubs or after school activities/hobbies. How about a job?
You might notice that I've left out some of the essential topics with my usual line of questioning. I rarely ask about Eating, and I don't think I've ever asked about Drugs, Suicidality, Sex, or Safety. That doesn't mean these things have never come up... I've had more than one patient in my career (adult and under-aged) tell me they're using some sort of marijuana product for their pain control. I've worked with a few patients who have had issues with suicide in their history and who bring it up as something to be aware of in their past. Discussing eating habits is a great way to assess the basic health understanding of the child and family or to gauge an understanding of the basic needs of the patient. I'm glad I can give out snacks to kids who may not have enough to eat.
Questions about drugs should include the use of alcohol, marijuana, or any other substance to get high in the past year. Those drug questions are followed by the CRAFFT acronym which stands for: Car, Relax, Alone, Family/Friends, Forget, Trouble. These are specific questions: Have you ridden in a Car where the driver (which could be you) was high? Have you taken drugs to Relax? Do you ever use drugs or alcohol Alone? Do any of your Family or friends tell you to cut back on your use of drugs or alcohol? Do you ever Forget things because you were using drugs or alcohol? Have you ever gotten into Trouble while using drugs or alcohol? This assessment can be scored to determine high risk of substance abuse. It was also discussed that kids are much less likely to have these conversations in front of their parents - and they're also more likely to talk about their friends than themselves - so asking your patient if any of their friends use these substances might get you more information than starting out asking them about personal use.
With kids who may have some mental health issues that need to be considered as a component of their care, adding these areas will be vital and incredibly challenging at first. But as healthcare providers, we have a responsibility to look out for these teenagers who may not have any other way to get help if they're in need. There were some interesting and startling statistics presented regarding some of the high risk behaviors. Particularly memorable to me were: 1) In a survey of high school-aged kids, 94% of the ones who used drugs or alcohol started between ages 11-15. 2) In a survey of high school-aged kids, less than half had engaged in sexual intercourse, but only 60% of those had used a condom. 3) Condoms only prevent pregnancy about 82% of the time. That's a B- grade. So too many kids are having unprotected sex and even those who are trying to be protected don't have the best stats on their side.
Dr. Breuner also discussed the importance of recognizing the rights of a teenager. In the state of Washington (this could vary where you live), a teenager can have their mental health records kept confidential starting at age 13 and their reproductive health records kept confidential at age 14. This means that a healthcare provider can discuss this information with the child and does not have to inform the parents - or anyone else - unless the child is being hurt or is hurting themself or another person. The information should be documented in their medical record but is not to be released to the parents. We need to be educated so we can serve as resources to teenagers who need help.
The second speaker was Sport Psychologist Dr. Elizabeth Boyer, owner of Northwest Performance Psychology. Dr. Boyer gave numerous examples of ways that injury can influence mental health. We see this in the clinic often - where an athlete is working to get back to their sport and is sad or depressed or fearful... for a wide variety of reasons. Athletes who are injured often feel like they have let their team down. They may lose confidence and could become more isolated from being separated from their teammates and friends. They should go to practice! Maybe not every single day, particularly if they need to be doing regular rehab appointments, but we can easily encourage injured athletes to attend a practice every week and be part of their team.
A key takeaway from this presentation was that developing some mental health skills for recovery can also help improve athletic performance. Skills like imagery - where you visualize drills in your head - or goal setting - in the short and long term - can both help with recovery and with performance. While we always set goals for our patients in the clinic, the patients should have more say in their own goals rather than having a therapist select things that may seem arbitrary. And reminding patients of their goals throughout the treatment so they can see their progress is also a useful tool.
Lastly, Dr. Boyer mentioned the importance of self-care as a healthcare provider. I love my job. Every day. I can't believe how blessed I am. But sometimes I forget how much of myself I'm giving to others and how little I'm giving to myself. Sounds like I need to find some different options for that for the new year... more focus on my own mental health will only help me better serve the patients I'm working with, and keep myself going.
And with that, a Happy Thanksgiving to all my readers. I hope you'll take the chance to care for yourself this holiday season. And to care for those around you.
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