::Attendees visible::

COMPUTER: 
Recording in Progress.

LACEY SORRELS: 
Good afternoon, I just want to welcome everyone today to our Lunch and Learn. This Lunch and Learn is being brought to you by a collaboration between Oklahoma Human Services, University of Oklahoma Anne and Henry Zarrow School of Social Work, and the Oklahoma Adoption Competency Network. We appreciate everyone joining during your lunch and noon hour. We want to get started so that we can make sure to respect everyone's time and the great information being discussed today. 
So first, let us go over a few housekeeping things for our time together this afternoon. First, we are recording this meeting. By participating, you are giving us your consent to be recorded. Second, help us reduce distractions so that we can all focus and participate. We have muted everyone to make it possible for everyone to hear the speakers. We want you to be able to express your thoughts and questions, so please utilize the chat for this purpose. We will be monitoring
the chat and questions will be touched on during our question and answer time, during the last 15 minutes of the webinar. We also want to be able to see you. So if you're willing and you're able, please turn on your video if you're unable that is fine also. To receive information about other post adoption events. Please list your name and email in the chat, and we'll make sure to add you to our contact list. Third, let's remember confidentiality. It's vital that we protect confidential information so that we will not be sharing specifics, such as names or details about adoption cases, people and/or children. Lastly, if you are a foster parent attending this training,  you will receive one hour of training credit towards the 12 hours of in-service training that you need each year. These trainings are not yet available as CEU credits for professionals. However, you may submit this certificate to your agency and request training credit per your agency's policies. Please indicate in the chat box if you would like to receive a certificate of attendance and participation. And please leave your email as well. Now I'm going to hand everything off to Dr. Coffey, who is today's presenter.

SARA COFFEY: 
Thank you Lacey, and thank you all for being here today. I'm going to share my screen and I'll be talking with you guys as I do that.

::Screenshare::

I'm really happy to be with this wonderful team and appreciate Dr. Goodwin

::Title slide - Medication Management::

I'll let you all know a little bit about myself, because I certainly think  And so I'm Sara Coffey, I'm a child and adolescent and adult psychiatrist. I've been involved with child welfare for several years. I was previously serving
as the director of clinical operations, and I've had to step back a bit as I've taken on the interim chair duties at my department here at OSU in Tulsa, but still provide psychiatric consultation. For those of you that know me, you might know a bit of my story. So I'm a daughter of a social worker that worked in child welfare, and prior to medical school, I was a case aide for two years, and really went into medical school to work with children and adolescents. Recognizing that in my, in my kind of journey that, medicine and having the tools that both medication therapy and certainly the wonderful wisdom of my mom as a social worker and thinking of the environmental factors, to work with children in the child welfare system is something that I kind of went on.
And certainly recognizing, too, that not all children come into families of adoption through child welfare. But that is, certainly a group of individuals that we'll be talking about today. And the role of, trauma and other instances that can certainly, I think quite often, have challenges in the way that psychiatrists and other clinicians are diagnosing children
with behavioral disorders. And so I want to talk about that today.
The other thing that I'll add to is that I've had the, the great opportunity, with the, support of Dr. Goodwin, to kind of
look more into adoption competencies. And I would offer that I am certainly not an expert, although there are wonderful experts on this call. I really want to view this conversation today through that lens as well. I appreciate any questions or comments you all have. Please feel free [unintelligible] Please feel free to use the chat for that too, and we'll have some time at the end of this talk to also answer some questions as well.

::Slide - Objectives::

Okay, so for our objectives today, I really want to talk a bit about the role of trauma in development. Again as a child and adolescent psychiatrist. Certainly whenever events occur in our life, we see, behaviors, we see stressors, and we see other ways in which not only children but also adults can react. And so we'll talk a bit about the role of trauma in development. I want to also talk about the way of therapy in treatment. Again working with children and adolescents, it's important for us to be mindful of the very impactful role of therapy. Quite frankly, the younger the child is, the more, integral that caregiver involvement is in therapy. And in full disclosure, in psychiatry and other mental health, oftentimes we haven't been good stewards of that. Kind of thinking about the individualized patients and other ways as well. But we want to be mindful that children grow up in the context of their family. And certainly whenever kids are struggling with psychiatric or behavioral disorders, that can impact families. And we want to make sure that we're, we're
encompassing all of the family whenever we are looking for treatments. 
And then what we'll also do is talk some bit about best practices for prescribing medications. I'm going to introduce you all to the, very long-winded title of the Pediatric Psychotropic Medication Resource Guide. And it's very long, but it's something that was developed by pediatricians, pharmacists, and child psychiatrists here in the state of Oklahoma. That was really intended to provide education for clinicians that are caring for kids. The reality is, is that, there's not enough child and adolescent psychiatrists, to really meet the need. And we have wonderful pediatricians, PAs, nurse practitioners, adult psychiatrists that are meeting the needs of children, but to have some best practices for prescribing, is really something that we want to make sure that we're all doing due diligence to make sure that we're not prescribing a medication that isn't appropriate and want to be judicious about the use of medications. And so we'll talk a bit about that. These guidelines are available, across the state, for clinicians that are treating children with psychiatric disorders. And they're, they were developed in partnership with Child Welfare, OU Health Science Center, OSU, and the Oklahoma Health Care Authority. To make sure that we are, judicious stewards of the medication, because medications can be helpful.
But I'm sure you all have seen this, too. Sometimes we go down on the kind of medication as only treatment route. And what I end up see happening quite often is that we get one medication and then another medication, and then another medication
added to kind of treat the behaviors without necessarily addressing the core of what might be contributing. And so we'll talk a little bit about that today. And again certainly happy to hear any of your questions or concerns about what this might look like within your own family, within your own children, to provide some support.

::Slide - ACE Study::

Okay. So we really can't start talking about trauma without talking about the ACE study. I offer this to you all as a medical professional. Because the reality is, is that when I was in medical school, goodness, even up until my kind of post-medical school training in adult psychiatry, we weren't talking about how adversity and trauma very early on was contributing to really any type of psychiatric rep or other medical illness as well. I offer the ACE study to kind of,
let you all know that I think we're in a different kind of an era of understanding how not only are there genetic components that contribute to, goodness, diabetes or high blood pressure, depression or anxiety or autism spectrum disorder. But we also know, too, that adversity and trauma and other experiences that happen in our life can certainly play a role. The ACEs study, I think, is very instrumental. Because in mental health, we certainly understood what we would call the bio psychosocial, elements of disease.
I'll use myself and my own family as an example. So, you know, I'm someone that can struggle with quite a bit of anxiety. So to can my mother and her mother as well. There's a genetic or heredity component to that, too. I'm also someone that maybe is a little bit introverted, and so kind of getting out there, might raise my anxiety a little bit. So that's kind of like the psychological component. And then certainly, you know, if I, let's say I had to, move or there was an issue
that my car got a flat tire or something else that was going on in the environment that was a stressor. All of those could compound and can contribute to the symptoms that I'm experiencing. 
I think we talk about this quite often in mental health, but the reality is our wonderful colleagues in medicine often didn't touch on that as much. We're talking about this more now. And it's not to say that, it's one or the other. I think the reality is, is that we have to look at individuals and families holistically and recognize that there might be a genetic predisposition or a genetic component that's contributing. But that also there might be other factors that can really, make disease states worse, make anxiety or behaviors or other things worse as well. And for this group, which I think is a good thing, is that we're talking about it more. Right?
And we want to make sure we're not shaming whenever these things are occurring. We're recognizing that these are problems,
so that we can address them. And quite frankly, before the ACEs study, at least in medicine, I don't think we had a framework to really talk about it in this holistic way. And so hopefully we're understanding more and more the complete holistic approach of what leads to wellness, as well as some things that can contribute to perhaps, functioning that can be impaired.

::Slide - Abuse, Neglect, Household Dysfunction::

So, again, I think another interesting thing about the ACEs study. You know, adversity can come in all times. Adversity and trauma can occur from, goodness, thinking about the torrential rains in California or the fires in Maui or tornadoes here in Oklahoma. But when Vincent Felitti and Robert Anda, the two that we're doing this study, were looking at adversity, what they found was that kind of the the most prominent adverse events that were happening were what I would call interpersonal. Right? So it was happening, not as an individual of like an environmental factor that's contributing to increased stress. But what's happening in the home, between the relationships that we have with people that we trust and that we go to trust. 
And as you can see here, the ones that really bubbled out as being more significant for mental health and disease states later on, were concerns of physical, emotional and sexual abuse, physical and emotional neglect, and then other household dysfunction. So again, I think we're these studies have been replicated state by state. We have an understanding that these types of incidents, can certainly increase, health in our adult people, adults like me and you are grown ups. But certainly we see this can have an impact on children as well.

::Slide - Trauma & Brain Development::

I often give these talks to school teachers and to others, just recognizing the role of trauma and brain development. I shamelessly stole this from the Ohio Department of Education. But I think it's a really lovely slide that kind of talks a bit about what our children might be experiencing when they've had these traumatic events happen early on. You know, and kids, as they get to kind of school age functioning, going to school feeling ripe and ready to learn. 
We often think that this kind of cortex, this purple part of our brain, is coming online so we can plan we can, kind of understand and problem solve. And in, quote, "typical development," you know, survival has been, well taken care of. We have kids that are growing up in very trustful relationships. Things feel like they're okay. Perhaps they're able to regulate their emotions. So whenever they're, tasked with something that's just beyond their ability to kind of, for them to kind of meet, they don't get real frustrated or dysregulated. They're able to regulate and do okay because they're regulating okay whenever they're interacting with grown ups or with children, their social and emotional responses. You know, getting their needs met. And then cognitively, they're kind of coming to school ready to learn. 
Trauma can really kind of flip that all on the head. And the reality is, is that the brain is an organ, just like every other organ that we have in our body. I'm biased. I think it's much more special than the heart or the lungs. Probably why I got into psychiatry. But so too, we can see this kind of, dysregulation or dysfunction, that that children are really, coming kind of needing to use a lot of that brain energy for survival, right? This kind of notion or fight or flight.
Who can I trust? What's going on? Because of that, they might be a little bit dysregulated because of the hormonal aspects
in the brain. But again, that kind of fight or flight response. Because they're dysregulated, they're struggling with social and emotional cues. And then they're not really able to learn in a way that we would expect them to whenever they get into the school setting. 
I put this slide up here because I think it is a good template for us to think about whenever kids are seeking mental health care for these kinds of issues. As we're talking about kind of emotional dysregulation, difficulty concentrating in school, perhaps you're thinking about oh does this child have a diagnosis of ADHD, attention deficit hyperactivity disorder? Does this child have disruptive mood dysregulation disorder? What is going on with this child that we can diagnose and then treat? And I would offer that, it can be a little bit, a little bit stickier than that. Right? It can be a lot of other things that are going on. And and for all of us to have a bit of grace and under and understanding what we often call the working diagnosis. That really as, as caregivers, as clinicians and as the child to really figure out what is driving the behavior. First and foremost is a really important part of knowing what to do next. And certainly adoption
competency as trauma-informed care is really important whenever we're working with children.

::Stages of Psychosocial Development::

So I love this slide. I'm a big Erik Erikson fan myself. First, I think it's great that he allows us to continue to have growth as humans even as we get older. I've kind of circled the younger years as well. Just like we have different
developmental milestones whenever you're taking the child to the pediatrician. You know, thinking about when a child first, sits up straight or first crawls or first walks, we have developmental milestones, social and emotionally as well. And you likely wouldn't expect your 11 or 12 year old, and you wouldn't have the same expectations for your 1 or 2 year old, emotionally, because they're not quite there yet. And same too, do we see this in social and emotional,
concerns.
Very early on Erikson talked about in infants, their, their real duty is to kind of understand who they trust, right? I don't know about you, I have two kids, but they did not come out of the womb able to care for themselves. They came out of the womb needing to have a grown-up to be able to tend to their every need. Right? Now, I was not 100%, being able to tend to their every need because I, too am human. But enough of the times, I was able to attend to their needs that they had an understanding of how they could trust the world. 
I'll offer a little bit here too, kind of thinking about infant mental health supports as well. You know, ages ago, we used to think kind of pre-verbal that if something occurred to a child
before they were born or before they were able to speak, that it wouldn't necessarily have lasting impacts. The reality is, is that we're learning more and more about how important these early life experiences are. I'm going to guess, goodness, that we're even having more understanding of intrauterine development and what that looks like. There's actually been studies that show that if there's a lot of maternal stress whenever they're pregnant, that there's a higher increase of oppositional defiant disorder and conduct disorder.
The reality is that there's just a lot more to know about how we are creating environments. And even for little ones that are intrauterine, that can certainly impact, behavioral and psychiatric symptoms later on. As kids get older, again, kind of their autonomy versus shame and doubt is something that Erikson was talking about. And you can see this with your toddlers, right? And they're kind of learning how to, advance themselves a little bit more. Goodness, I feel like this can be the hardest thing because they have all the will in the world to do whatever they want to do, but no executive functioning to know how it's going to play out. So guess what? As the caregiver, you are executive functioning for these little people. Again, depending on, kind of where these traumatic experiences can occur, you can see a little bit of stunting that occurs here.
Initiative versus guilt we see in our older kids. And quite often the kids that are coming to us or our school age children, this, this kind of blue marking industry versus inferiority. Erikson really thought that kind of our school age kids our 6 to 10 year olds. Really, you know, their developmental milestone is to feel competent in their ability. And in our Westernized society, their ability is often around school. And so you can imagine if you're kind of socially, pre predetermined to feel good about something and you're not doing well either because of, let's say, learning disorders or because of emotional dysregulation, that it's just this snowball effect about how that can really impact how we're doing.
So so I offer this again to kind of set the frame about what I'm thinking about whenever kids are coming to see me kind of getting a good history about when something occurred, and also being mindful of too, certainly kind of thinking, through the lens of adoption competency that, you know, kind of have it in, in introducing somebody into our family and feeling like things have been okay, but then still having these remnants of something occurred. There might it's important to kind of take in mind the context of, of individuals throughout their journey. Because somebody might be struggling, with something early on that things are going a little bit better. And then we're revisiting, some symptoms that are occurring.
And because I don't know about you, there's a core of me that's still very similar to how I was when I was an adolescent. But hopefully I've done a lot of growth, and I'm much different. So I might be understanding something differently now, as I've gotten older and kind of experiencing things. And we certainly see this with kids too, right? They're starting to understand who they are a bit more as they get older. And so symptoms can kind of flare up as well.

::Slide - Graphic of brain with parts labeled::

Okay. So so I put this on here. So about the same time that the ACEs study was going on, there, the Massachusetts Policy Initiative was seeing a similar thing for kids coming into their setting as well. That kids were often, referred for treatment for behavior concerns. And what we find, actually, when we do group to group comparisons. So this wouldn't be something that you would refer a kid to get testing or an MRI to see, like, does the MRI show that he's had trauma? But when we show individuals that have had more traumatic experiences compared to those that don't, we actually see changes in the brain. 
And so we see changes with kind of this, what we call hyperactive amygdala. This kind of fight or flight response might be more on board. When that's more on board, this kind of cortex, this outer layer of the brain, it's harder for them to function. This is a really important piece in how we're engaging with each other, how we're learning about things. Again, kind of diagnostically can look like that ADHD, anxiety, other things as well. And we can also see changes in kind of language and other things there too.

::Image of bridge::

So what we see sometimes is that kiddos that have a lot of a traumatic experiences, perhaps are not using language
as like as a bridge. And this might be because we actually see changes in what we call the Broca's, language area that they can't necessarily understand what is being said to them. And sometimes, too, they can't really, let people know what they need. And so instead of becoming kind of a bridge

::Image of brick wall::

for having a conversation, it becomes more of a wall. I certainly see this quite a bit, when families are coming to see me. Goodness, as a human too, I'm sure that I've used, language as a wall as well, but just kind of keeping in mind, I think the complexity that there can be not only biological, attributes that have occurred, in a young child's brain,
but also to sometimes, like perhaps if language has always been used as a wall and not as a barrier, environmental impacts that can contribute.

::Image of slot machine::

And so as a clinician, you know, it's helpful for me to kind of I got to be thinking about all of these things, right? And hopefully any clinician that you're working with is also taking a very holistic viewpoint of what's going on with the child. And that's why in child psychiatry, we often talk about the working diagnosis. I know this can be very hard for families to hold, and for me, too, it's hard to hold as well. But we, because kids are constantly they're kind of a bit of a moving target and always, developing differently. I do think there is something about kind of holding and working with families so that we're not pigeonholing a child into having this diagnosis, and we're not thinking about other factors
that could be contributing.
So why do you have the slot machine here, Dr. Coffey? Okay. Well, let me tell you, because I think the other interesting thing that happens sometimes that we see, and this is probably more for children, even Pre-Verbally or early on, you know, I kind of mentioned that notion of trust versus mistrust, of needing to meet the mark at least most of the time to get a
child's needs met. The reality is, is that many of our kiddos that come into the child welfare system or that perhaps are going towards adoption, they have not had that consistency. Right? And so, I give an example, you know, of little Billy maybe is 3 or 4, and he skins his knee, and then, goes to his caregiver that perhaps has their own substance use disorders or other factors that are contributing to not be able to meet the need. And every time the child goes to get their need met, it's a different response, right? So maybe one day the response is that there's a loving embrace. The other day he's gotten yelled at. The other day he's ignored. The other day he might be, you know, goodness, physically hurt or something like that. There's this kind of variable response. And because the brain kind of comes hardwired to learn, but we're giving him that software. The software that this child is getting is often that there's no kind of real cause or effect. And this really matters for learning as well, because if you've never had the experience in your life that's so variable, that's all over the place that if A happens and then B happens, then C is next, or that one plus two always looks like three.

::Image of graphs regarding linear and no linear relationship (superimposed over slot machine image)::

There's not this kind of linear response for growth and understanding and it's all over the place. I say this to you again
because, this is often whenever kids are come to refer to see me. Again, I keep on talking about ADHD, and I hate that I'm not trying to demonize ADHD. And the reality is, is that attention deficit hyperactivity disorder can often be comorbid
when these other things are going on. But if we're not thinking about how trauma, about how early life experiences or what also occurred played a role, we might be missing the mark. And so just keeping in mind, I think, the complexity of kind of how did we get here, recognizing that behavior has meaning can be very helpful. And oftentimes as caregivers, as foster
parents, as are adoptive parents, making sure that we're advocating and that we're working with clinicians that have an understanding of this can be very helpful. I say that and I know that can also be hard as well.

::Slide - Trauma & School

Because the reality is, I think that we're getting better at looking holistically, at children, but sometimes for a variety of different reasons, we could do better. We can continue to do better. As I mentioned, you know, about the same time that the ACEs study was going on, there was also this report about a dose-response relationship between adverse childhood experiences and student learning. If I didn't make that explicit, what the ACEs study showed is that the more, the more ACEs that you have, the more likely as an adult you're going to have concerns for diabetes and chronic health concerns. Many of us that study adverse childhood experiences talk about this in the public health domain, and that we really want to do something about it because it's so prevalent. And we know that it has these impacts. 
So in trauma in school, as I mentioned, we can see these, interactions occurring with children. And so kids that have this type of dose-response relationship or two and a half times more likely to fail a grade. They often score lower on standardized achievement test scores. They can have more of that receptive kind of understanding language and expressive, being able to talk about what their needs are. They're often suspended more or expelled more frequently and designated
to special education more frequently. And again, I put this up here because, you know, having this kind of adoption
competency, trauma-informed lens. We might be the ones that need to kind of educate and to kind of talk with schools about it because we might miss something. And it's not to say that it can't be a both/and, right? Children can certainly have
an underlining learning disorder, as well as having perhaps, experiences that are occurring in the context of their adoption story, or through trauma. But we might need to make sure that we're educating and looking at that from that regard as well.

::Photo - student laying head on desk while working in a math workbook::

So a student who appears perhaps lazy and not interested in completing work may actually be afraid to follow through out of fear of making mistakes. And this kind of goes to Erikson's, you know, thought about initiative versus guilt, right? Perhaps in the past, anything that was, they tried to do on their own was really pushed down or they got in trouble for it. We, we have a tendency to kind of keep these things with us a little bit. And so, again, being mindful of the whole
totality of children can be helpful. And again, approaches that address only the behaviors that appear on the surface often don't respond to the student's needs.
You'll hear me often talking out of both sides of my mouth during this time, too, right? Because it might not always be the case. Again, there might be somebody that and perhaps they're kind of lazy or uninterested is because they're not getting enough sleep at night. Or perhaps there really is kind of a single learning disorder that they can't really attend to. But it really behooves us to be curious, to really seek to understand. And certainly if we have an intervention that's in place at school or in therapy, and it doesn't seem to be working, to really be kind of reconsidering, do we really understand what's going on? And to kind of continue to be curious about what's driving the behavior. And so that'll be my continued soapbox. So let's continue to be curious with kids so that we can really figure out what's driving.

::Photo - student sitting on a bench outside of a school::

Again, elementary and middle school students can experience anxiety and fear, decreased attention and concentration, withdraw from others, increased activity level, angry outburst, distrust in others, absenteeism, increased somatic complaints. So kind of we often see headache, bellyache associated with anxiety, difficulty with authority. And again, I kind of put this on here thinking that, as a psychiatrist, if I'm not looking through a trauma-informed lens and adoption competency lens, I might see these symptoms. And say, oh, this kid has oppositional defiant disorder. And again, he might meet criteria for it. And I might be able to do an intervention that's addressing it, and things might get better. But if things aren't getting better, and I'm not looking into the totality of this child's experience, it would be helpful for us
to make sure that we are doing that. And as caregivers, we're advocating for that, too, because it might be a both/and, right? And if we're missing the underlying core of what's going on, and that can be challenging too.

::Slide - Diagnostic Challenges. 
[Image of white puzzle with 1 red piece]

And again, that poses diagnostic challenges. And I'll kind of I'll tell you a little bit how I think about this too, as a clinician. You know, I was talking about like, I'll kind of use a medical term for it. Sometimes, we use medications to kind of treat the symptoms as well. And that might be appropriate. Right? If they're safety concerns, if it feels like things aren't working. It's kind of, but I also think too, it's kind of like if I was a pediatric ER doc, and a family, kept bringing a child in for an exacerbation of their asthma right there, asthma's getting out of control. The child is at risk of kind of having respiratory complications. I'm going to treat that child with the medication with kind of a nebulizer and other medications to help open up his airways, but if I find out the reason that he's having kind of this asthma exacerbation is because of mold in the home, and I'm not doing anything to address the mold, then all I'm doing
is treating the symptoms.
And I think that's something that in mental health, we have to be mindful of too. There's a role in treating the symptoms,
certainly with therapy and medication. But goodness, if I'm not getting it to the core of what's going on, all I'm going to be doing is treating the symptoms. And we really need to be kind of holding both and addressing both at the same time. But that can be challenging, and it's challenging because kids are kind of growing and they're developing. Kids develop at different ages. Kids are always in different environmental stimuli. You guys know this.
As grown-ups, we have much more agency to determine where we want to be. And if something's not working with us, we could, we often have our coping skills and other things. We might see a light at the end of the tunnel. We might be able to leave that job or do something else. Kids are really beholden to what we need them to do. And I will tell you too, as a child
psychiatrist, trying to get rating scales from across different teachers, so common to see kids do well in, you know, their third and fourth period with a teacher that really gets them and really struggle in another. This poses a diagnostic challenge, right? Like, why is this kid doing so well here and not doing so well here? It takes more time. It's really important for us to be curious about what's going on so that we can really get to the issue.

::Slide - PTSD 
[Graph - Developmental Trauma Disorder, discussed by presenter] 

Okay, so I put this on there, too. And Dr. Goodwin's probably like "God, Dr. Coffey, When are you gonna start talking
about medications?" And I promise I will. But I want to I really wanted to set the framework about, honestly,
just how complicated this is. And why I think it's important for us to be very thoughtful and mindful about our diagnoses with children. And certainly not rule out, trauma and other factors, too. 
So this comes from some, a study that was looking at constellation of interpersonal trauma symptoms and child welfare. This is a study that I often kind of rely on. You know, as you can see here on this right hand side, that up to 70% of the kids are having or having functional impairment. So what does this mean? They might, you know, be struggling in school. They might be struggling with their relationships with their caregivers or with other kids in the home. And that's   pretty big jump, right? 70%. But as you can see here, only about 30% were actually, having what we would call post-traumatic stress disorder symptoms. And what I'd offer here is that, certainly in the medical model, we're often, clinicians are trained to get the diagnoses because we have a lot of research that supports if you have this diagnosis,
then you're going to do this treatment. And that's why it could be a little bit challenging, right? Because you might have kids that are contributing with all of this. They're not necessarily meeting criteria for PTSD, but they might be meeting criteria for attention deficit disorder or disruptive mood dysregulation disorder. And quite frankly, a good clinician would want to figure out, like diagnostically, what's going on. 
You all know your kids best. I think that's a really big thing, too, is that we have to be mindful that this is a team-based approach. And that families know their children's best. We really want and children to kind of tune into too, what their struggles are as well. But really, we should be asking of our clinicians to make sure that they're bringing to you and kind of disseminating the research that they are looking at to make those best decisions. And so that's really why we're kind of thinking diagnostically about what's going on, and quite frankly, why sometimes we might, assign a diagnosis and kind of go down that pathway or treatment to see if it gets better. But it is always kind of a work in progress and should always be a team conversation.

::Slide - Trauma/ADHD 
[Venn diagram]

The other thing I mentioned too, because it isn't uncommon, and we do see a lot of overlaps between ADHD and trauma, and this adds to some diagnostic difficulty. As you can see here, kind of the overlap is difficulty concentrating, easily distracted, and doesn't seem to listen, to disorganization, Hyperactive, restless, difficulty sleeping. Whenever I'm training clinicians or others like, quite frankly, I've always letting them know that any time a child is coming into your office, we want to make sure we're doing a good history of understanding what's going on. And because it might be  both/and, right? There might be a strong family history of ADHD, the symptoms might really look like ADHD, and you might treat them, with the best research that supports it. And things might get better. But again, if we're not looking at trauma, if we're not looking at these other environmental experiences that might be contributing, we might be missing the boat. So just continuing to be curious, again, advocating and talking with families. And, and I always say too I think the proof's in the pudding. Right? So if we're doing something, it's not causing any harm and things are getting better. Well,
that's really what I want to see. Right? I want to make sure that that the child's feeling better, the families feeling better, that we're functioning okay and that things are improving.

::Slide - General Principles & Mentoring::
[blue, green, yellow, red paint splotches]

Okay. And so I mentioned this resource guide that again is available online. It really is targeted towards clinicians that are treating. But I want to let you all know because this really is best practice that's set here in Oklahoma. And, and I would offer to you something that you should come to expect from those that are treating your children.

::Slide - Key Points in Psychiatric Treatments of Children & Adolescent::

I think it's really important. What is offered is that really the first line treatment for the majority of psychiatric illness should, should include behavioral therapy. I put this on here, too. It's just important to know, you know, I kind of joke with my the patients that come to see me, it's kind of like if you are wanting to build muscle, and all you're doing is taking a creatine supplement or a protein supplement and not really working that kind of muscle. It's not going to be very helpful. Therapy is kind of like, you know, going to the gym for the mind. And we often get into kind of
behavioral components and other habits too, that might kind of lay down a foundation that aren't very healthy for us. Therapy is really important. The younger the child, the more important caregiver involvement is. 
And I would just offer that to you that we often see probably more robust results whenever caregivers are involved. And certainly, for, for me, if I'm doing therapy and I'm seeing the child one hour a week. The reality is, is that the majority of the time, they're, they're at home with their family or in the school setting. And so caregivers are just so important. We also know, too, that whenever kids are really struggling, that we struggle as caregivers as well. And so just keep in mind the importance of caregiver involvement in that therapy. I can't stress that enough. And the other thing too, when we think about medications, and certainly as a child psychiatrist, I'm here at the adult, inpatient unit and I'm talking with my, adult residents. But we always start low and go slow. Children, are kind of tricky because they can be metabolizing medicines very quickly. But we also want to make sure we first, do no harm. We want to make sure that we're at the lowest possible dose that really treats the symptoms. And so we can kind of slowly increase to make sure that we're doing that. 
The other thing that we want to be mindful of is avoiding polypharmacy. So what does this mean? So polypharmacy is multiple medications. The one caveat to that, again, is in ADHD, actually, for attention deficit hyperactivity disorder, there are some good studies that show that a combination of a stimulant medication, these are medications like Ritalin,
Adderall, in combination with a what we call an alpha agonist, like Intuniv, Tenex, guanfacine, you might hear sometimes those two together can mean that you need less of both of them kind of decreases the risk of side effects. And that could be helpful. 
The other caveat to that, too, is that sometimes we have children that have multiple diagnoses, and so they might have a diagnosis of ADHD and anxiety, that both are not perhaps treated, adequately enough with therapy. And so you might have a child that is taking a medication for anxiety and a medication that is for ADHD. I know Dr. Goodwin knows that we see this too. I just in my line of work, I'm constantly seeing kiddos that are coming in on multiple medications and things are not better. I will offer to you if you've had experience where you feel like a child is on multiple medications and doing better, please let me know. I want to hear about that because I think in my line of work I don't see that. And again, important to kind of know that. And for what it's worth, again, the proof is in the pudding. There are some kids that we might need different medications. And if things are going well and things are okay, then we certainly want to make sure
that we're not disrupting that. If there's side effects, that's certainly a different story. And I don't want to say that we don't do polypharmacy at all regardless, but we want to be thoughtful and intentional about medications. And again, I'm looking at the child to see how the child is doing. Are they doing better? Are things okay? We need to really have that individual support. 
The other thing that's really important too, is that as the caregiver, as the parent, you need to consent to medication. This is really important too, that we need caregiver's permission to be able to do that. And we also need what we call the assent of the child. And the older the child is, the more important it is for the kid's buy in. I would offer that any time a child's coming to see me, I'm asking them about the medication. I want to know if they're having any problems with it. I want the kid to know what it's helping with. Right? And that depends developmentally on what the kid is doing. Quite often the child is telling me I feel better with it. I want to hear that from the child. It's important for our children
to have a sense of agency. Again, through the kind of lens of adoption competency, recognizing that children have their own sense of agency and choice is important. But also, just in the spirit of being a child, we want to make sure that they know what they're putting into their body and that it's helpful. I want to be monitoring for side effects. And again, as I mentioned, children might metabolize quicker than grown-ups. And so it might not be, it might, you might often see sometimes as a caregiver, we're trying to increase the dose of the medication. But perhaps they're getting too much of it at once. And so my adult colleagues are always questioning, why are you giving this medicine twice a day when it's  typically indicated for one time of day? Part of that might be because the kid is able to kind of metabolize it quicker, and too much at one time might be too much. So again, I would just offer that all of this should be a conversation with the caregiver, the treatment team, and the child, to kind of make sure that you're all on the same page and permission too, in partnership with your team, to ask if you have questions or concerns. I think that's really important.

::Slide - Who Can Prescribe::

So I put this on here, too. I thought this would be good to kind of know who can prescribe here in Oklahoma. You know, quite often our pediatricians, family medicine physicians, adult general psychiatrists, are prescribing, just to offer that child and adolescent psychiatrists, have gone through medical school. They've done 3 or 4 years of adult training, and then two additional years of child psychiatry training. And so I certainly feel that, with regards to kind of expertise and training, that child psychiatrists are probably the most appropriate. I should have put on here to developmental pediatricians, which I would also, you know, say that they had additional training working specifically with kids. And for any developmental pediatricians that are on this call, my apologies. I'm just realizing that now. And so Mea Culpa for doing that. But they certainly do a great job too. And nurse practitioners and physician assistants, with guidance can also be and prescribing as well. I will offer to you that I have and again, being here in Oklahoma, I've seen every single person kind of prescribe and, and many of them are doing great. And some even child psychiatrists, I've had
questions about what they're doing too. And so, although I do think child and adolescent psychiatrist and developmental
pediatricians have more training, really want to make sure that you're feeling comfortable, that you're trusting the person that you're working with, and able to have those conversations. It's just really important. And again, I think pediatricians, family medicine docs and others can do a great job, working with kids and the nice thing is, is that in Oklahoma, we have a lot of really good supports for people, if they're feeling like they're practicing and needing a little bit more help.

::Slide - General Principles & Monitoring::
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So some general principles before initiating medication, we really want to make sure that we are, having a good conversation. Right? Like, I quite frankly, I'd be a little bit leery if I was going to see a doctor, and I was in there for five minutes, and then they wanted to start a medication with me. I would that would, make, turn me off a little bit.
And I'd want to make sure that the physician is doing a good job asking questions. You know, kind of figuring out what's going on and really making sure that we're getting adequate medical history from people that are on the call. What I'll say, too, is that many of our, kind of CMHCs and others, like, they might have treatment teams that are talking to the the physician that's prescribing medication. So keeping that in mind, as well as that it might not be happening in that office, but that doesn't mean they're not getting information from others. And to feel comfortable asking questions and making sure your answers are getting met.

::Slide - General Principles & Monitoring::
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And then, as I mentioned, each clinician should determine their comfort with diagnosing and treating. Again, as families, you should feel comfortable expressing your concerns. And I think the big thing to, like, in partnership, I'll just say, also just being mindful that that clinicians are coming with the information that they have, from their research and from their training to make the best decision.

::Slide - General Principles & Monitoring::
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But as caregivers, you guys really know what's going on with the kids that you're working with. The other thing that we talk about is having an interdisciplinary plan, right? As I mentioned, behavioral therapy is really one of the most important things that we're doing. Medications certainly play a role. But oftentimes it is working with the family, the school, the preschool, medications, therapy, and making sure that we're all working together. I wish that medicine was a silver bullet. You know, sometimes it feels like it can be. But the reality is, is that it is often a multi-pronged approach for healing. Just like we see in kind of medical illnesses, too. And in psychiatry and mental health, it's no different.

::Slide - General Principles & Monitoring::
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We want to monitor for treatment. Providers might do, like, a rating scale with you. So they might be asking some of the same questions. And again, this can be helpful. You know, we do this in medicine as well, like taking somebody's blood pressure. Their blood pressure is high. I'm giving you a medication that's getting your blood pressure lower. I'm going to be checking your blood pressure when you come in. So, too, will your team likely be checking rating scales to kind of make
sure that symptoms are getting better. I know sometimes this can be laborious. And so, like, why are you doing it? But it does help to get some quantitative data in addition to hearing from you all what the goals of treatment are. And that's one thing we want to make sure we're doing too.

::Slide - General Principles & Monitoring::
[Image in right margin - medication bubble packets]

And as I mentioned, we want to make sure that there is informed consent that you kind of know about the potential side effects. I will offer to you, too, you as a physician. Goodness, whenever they're doing their studies, anything that occurred has to be listed as a side effect. And so if you're somebody that gets super worried reading the insert of the medications, just keep in mind that, there's context to that, right? And if I have somebody that I started a medication and then they got a foot fungus, and if there's no reason why that medication should cause that, I'm likely not going to think it's a side effect of that medication. If I start a medication like an SSRI that is known to have some like GI distress or headache, and you get a little bit of a headache for it, then. Yeah, that's probably a side effect of the medication. When I'm talking to you about side effects of medication, I'm not going to give you the whole laundry list of everything that happened. Because the reality is it's quite small that that's going to occur. But as a physician, I'm going to let you know what is a potential thing to look out for. Quite often the side effects improve, and after people have been on it for a while, and certainly as a caregiver, if you have specific concerns, good to make sure those are
being addressed in the outpatient office.

::Slide - General Principles & Monitoring::
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The other thing to kind of talk about, too, is what constitutes a treatment failure. Right? It's not uncommon, that we, and I hear this quite often, families coming in and they don't want to, you know, there there's a feeling, I feel like I'm a guinea pig or I don't want to try this stuff. I mean, the reality is we're doing that all the time, quite frankly. Like, I'm trying new food to see if I like it. It, does it upset my tummy? And medications, certainly as clinicians, they're using their best evidence based on their research to see what's going to be best for you. But we know that medication is individualized. And so quite often, you know, we might have to, to try a medication. Typically we, as I mentioned, we start low and go slow. So we might start at a low dose, low dose of the medication, but then in to increase it to see if it's going to be effective. That can take some time. 
I'll offer to you this is, I feel like a clinical pearl that I give to my trainees, and I'm going to, I'll invite you into it, too. I feel like, I often ask, family is like, how long has this been going on for? Because it's, it's not uncommon that we're presenting in kind of this, this urgent crisis on something that's been going on for a while. And I want to be realistic too, that it might take some time to kind of make things better. As a clinician, I certainly want to do some interventions in the office to kind of make things better right there, but just being mindful that it might take some time for symptoms to improve. And that we can do some things in the meantime. But what we often need is for families to kind of stick with us. Unless there's really significant concerns. Right? 
Like if a child isn't necessarily improving as quick as I want them to, but there's no side effects to the medication, I'll likely have a conversation about increasing it. If we start a medication and side effects are really bad, then yeah, we're probably going to try something else. And so that's what I mean by kind of an adequate trial. And just keeping in mind too, that, we want to, it sometimes can take some time to kind of get those improvements as well. What I'd offer to you is that as a caregiver, I know it's it can be challenging. I'm a caregiver too. I have two small children. Goodness. Don't ask me if they're up to, I think they're up to date on their immunizations when I see that. But, like. But  everything else, I forget these things as well. Right? We're human. But, but kind of knowing what your children has taken, what their response is, can be very helpful for clinicians if you're going to a new clinician so that they don't, you know, kind of repeat the cycle of something that wasn't helpful.

::Slide - General Principles & Monitoring::
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And as I mentioned, we really need clear rationale for using medication combinations. This is just, it's just, it's good practice. I will say to you, what you see sometimes is that maybe a medication has been helping a little bit, but not just enough. And so it might be an adjunct or add an additional medication to it. That's okay. Again, it's in the context of kind of talking about the individual. The proof is in the pudding. But we want to make sure we know why we're starting a new medication. Again, what I often see, it's like we've started on something. It's not necessarily causing side effects,
but it's not really better. And then we start something else. My question is often, well, are we going to come off this other medication? Right? The other thing I'd say with this, too, I think best practice is to not do more than one thing at a time. Why is this? Because if we do two or more things at a time, how do we know what the effect is? Right. So if I have stopped your Lexapro and then started Depakote and things get a lot worse. Well, I don't know if they got a lot worse
because we stopped the Lexapro or because we had the Depakote, or the combination of the two. So I'm a big advocate, unless there's a significant safety concern of doing one thing at a time so that we can know the cause and effect about how things are going. 
The other thing that I often see happen, too, is that we kind of get in this cycle of, oh, we've started a medication. Maybe it's a little bit effective, but now there's a side effect. So now we're adding another medication. I staffed for another kid where it's like, then there was a side effect of that medication and it was like, hold on. Right? If we're going the pathway of that, we're doing medication, medication, medication for side effects. Somebody needs to have a judicious conversation about how did we get here? Because the reality is, is that there's a lot of medications that are out there. And sometimes it is about finding the right one, the right dose and the right timing that's really treating the symptoms without the adverse side effects. Speaking out of the other side of my mouth, what I'll also say, too, is that we're always weighing the risks versus benefits. And I've certainly had kids that have been on, different medication trials. And that the one that they're on right now is really helping them a lot, but they are having the side effect. That's a conversation I'm having with the youth and the family as well. Well, is the benefit outweighing the risk? And quite often it is, but for each individual it's different. For each context it's different. So having those conversations
are real helpful.

::Slide - General Principles & Monitoring::
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When we're discontinuing a medication, and the reality is, is that we should discontinue medications. Sometimes not, depending on the severity of the symptoms, the chronicity of the disease. But quite often, we might, especially if there's kind of a, an incident of let's say like depression that's coming on that was needing medication but wasn't real severe. Perhaps this was the first episode. Therapy was in place. We might consider coming down off of the medication. And that certainly is warranted. Sometimes, we see that symptoms return. And again, it's always an individual conversation, about what we should do. Same principle applies that I would make one recommendation, one change at a time, and kind of slowly
come off of the medication to make sure symptoms aren't bubbling back up again.

::Slide - Questions::

So again, I'm happy to kind of entertain any questions that you guys have about medications. I know, so like this was kind
of a foundational conversation about what a, a psychiatrist or a physician thinks whenever they're starting a medication. Certainly happy to answer any individual questions that you guys might have about specific medications, but I would offer to you that, you know, certainly feel comfortable talking to your clinicians. If you need to write it down before you go into the office, I think that can be very helpful, too. And, and in my mind, I do. I think it's best practice. It's just good care that if I have somebody coming in with a concern, I want to hear about it. And as somebody that's part of your treatment team, I need to make sure that we're on the same page. Nobody should ever feel, that they they don't have the opportunity to talk with their doc, their clinician, about what they're putting into their body. Well I'll kind of stop there.

::Attendees visible::

BONNI GOODWIN: 
I definitely want to, invite anyone who would like to unmute and ask questions to, to do so now. I haven't seen any in the chat, but I do know I have one, Dr. Coffey. You had mentioned the resource guide and that it's online. Do you have that link at the ready, or could you tell us what to Google to find the link to put it in the chat?

COFFEY: I will, I'll give it to you. I'll let you know that really it's intended for physicians and clinicians. And so it's not, I mean, although I think there are some things that can be helpful for families, but it really is, it's more of a clinician tool, what I might say. 

GOODWIN: 
Gotcha.

COFFEY: 
But happy to put it in there.

GOODWIN: 
Thank you. Any questions for Dr. Coffey?

SORRELS:
How often would you recommend a medication review? So we a lot of times kiddos in, you know, foster care or once they've reached adoption, they have that kind of like laundry list of medications. How often would you recommend that those, medications be kind of like just overhauled, reviewed?

COFFEY: 
I think the review is a, so I get those too. And what I would offer is I think the, here's what I would recommend. I think the review should occur with the person that is prescribing the medications. I really do. I think if we have concerns
about that person prescribing medications, it, then maybe we should think of a different provider. Quite often what happens in our office, we see somebody for an initial evaluation. We might see them, every 2 to 4 weeks following that, to kind of understand what's going on. The longest I typically go for seeing a child, would be three months, if things are going okay. And if I'm making changes or adjustments in medication, again, 2 to 4 weeks, kind of seeing kids to make sure that they're doing okay.

SORRELS: 
Awesome. Thank you.

CARLIE VAN WOERKOM: 
What? Hi, Dr. Coffey, What, like tips or tricks would you give to an adoptive parent who is trying to advocate for their child because they are seeing struggles at home that maybe the prescriber isn't picking up on or isn't maybe, maybe listening to?

COFFEY: 
Yeah, I think that's a great question. And I think, again, it can be helpful to kind of bring in there what the goals for treatment are, and letting the prescriber know. And, and again, I think it's challenging, but if you feel like you're, you're not being heard, I think it's okay to say, hey, I'm worried that we're not on the same page. I'm worried our goals are different here. And then really having that conversation, if that's the best person to continue to treat. I, I, I think starting there would be good. What the clear expectations are for the goals and then letting them know you're you're feeling that you're you're not being heard. Is there a way that we can work together to kind of get the needs met? And the reality is, is that it might it might be worth kind of considering another provider that can really meet
your needs where you're at.

VAN WOERKOM: 
Unfortunately, a lot of families live in rural areas where there's maybe only 1 or 2 options, and so they really don't have the option to switch. As far as medication management goes, and a lot of families wouldn't have this as an option
because of transportation issues. But, I mean, it would be reasonable to maybe have to drive a couple of hours once a month or something like that. I mean, that's an okay thing to do with this, right?

COFFEY: 
I think so, I mean, I think it depends on the individual and what's going on. I think you're, you're right, like quite often kind of child psychiatry and specialists, even outside psychiatry are more in an urban areas. And I think really depending on kind of what the needs of the child are, it might be something that it can be helpful to get connected with somebody that can really get a good diagnosis and kind of get a good treatment. Sometimes what happens, too, is that it
might be that that needs to happen first, and then perhaps the treatment can be transferred over to the primary care doc
or somebody else and then check back in. But, but I do what I would offer too, is I think especially if it is impacting functioning, especially if it is, severe and safety concerns, like I think we should view it in a same way, like if we had a child that had a significant medical concern. Right? 
Like if you had a child that had a cancer, had something else that was going on and we were relying on somebody to treat it and things weren't getting better. We would likely kind of seek out expertise and we probably would drive, you know, 3 or 4 hours. We might drive across state to be able to do that. And the reality is, is that for behavioral health, sometimes that's no different. You know, kids, are, there's safety concerns. They're not in school. There's other things that are going on. And we might need to kind of get that expertise that's there, to make sure that the child is getting what they need. 
So I know that's a hard answer. And I know and certainly, Carlie, I appreciate you kind of setting the reality of it, too,
that resources are very slim. What I'll offer, too, just so you all know and certainly you can feel comfortable telling your primary care doctors about it. We have a child psychiatry access line that's available. And so I'll put that in the chat, too. Again, this is not for families to call in. But it's for primary care docs that are caring for children in the rural community to call and talk with the child psychiatrist from 9 a.m. 'til 5 p.m. any day. So that we can kind of meet that need and can be very helpful too. And I certainly have, as I mentioned, I've seen a lot of different clinicians that, are doing their best to provide that support. And so sometimes it is I think you guys have great, social kind of communication kind of finding who might be the best fit for you. And they too can have access to those resources to kind of call and get the supports that they need.

VAN WOERKOM: 
That's awesome. Thank you.

COFFEY: 
You're welcome.

GOODWIN: 
Yeah.

COFFEY: 
Thank you, Lacey, for putting that too. That's a little bit of my soapbox. I think, you know, we often don't talk about that. And again, just, like physical health needs have different levels of severity. The reality is, is that many of our kids are, are struggling. That, you know, up to in adolescence for sure, suicide remains like the second leading cause of death for adolescents. And so certainly, I think it's something that we want to make sure that we have accurate diagnosis and treatments and supports for family. And so to kind of highlight the need to make sure we're getting that expert care is really helpful too. 
I want to offer too, I'm going to apologize for you. Dr. Madina mentioned that my texts are going off. I have some rowdy bunch of girlfriends that are texting me, and I apologize for any cursing that was on there. I just saw it. I'm a little mortified. So thanks, Dr. Madina for letting me know, and apologies for you all. I'll be sure to talk with my lady girlfriends about their frustrations.

GOODWIN: 
Any other questions? As we get ready to wrap up? Awesome. Dr. Coffey, I can't thank you enough for your time and and all of the amazing information that you shared with us. Very, very grateful for that. And, Lacey, I'll turn it over to you to wrap us up.

SORRELS: 
Yeah. So we just want to thank again, Dr. Coffey, and then everyone else for joining us today. And so in the chat box, we're going to, have a QR code that will take you to the Adoption Competency page on OKFosters.org, And then there's where you can find some of our, upcoming events and some additional resources. Also, we had a few that joined after the beginning. So I just wanted to remind everyone that if you do need that participation certificate, please go ahead and drop your name and your email in the chat box, and we will make sure we get those out. They should be out to you guys by the end of the week.

GOODWIN: 
Excellent. Thank you so much. Have, stay cool and have a wonderful rest of your day.

COFFEY: 
Thank you. And I put the OK CAP map in the Zoom chat for you guys. So good to see you.
Take care. Bye. 

GOODWIN: 
Thank you.