CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
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understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Mental health in children and adolescents
This tool provides information to facilitate the identification and management of depression in children and young people 5-18 years old.*
Disclaimer: Healthcare providers are required to practice within their respective scopes of practice. Patients should be recommended to an appropriate healthcare provider when necessary.
Focused examination
1. Patient History
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Address psychosocial risk factors that could be contributing to depressive symptoms.
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Identify and assess other conditions or co-morbidities.
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Conduct a family history of psychological conditions including parents and grandparents. If required, provide collaborative management with appropriate healthcare providers.
Psychosocial Risk Factors:
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Age, gender, family discord, turbulent interpersonal relationships or social network, bullying, physical, sexual or emotional abuse, drug and alcohol use, history of parent depression, single loss events, ethnic and cultural factors, homelessness, refugee status, living in institutional settings, combination of multiple risk factors
Examples of other conditions/co-morbidities:
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Physical conditions: back pain, headache
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Psychological conditions: mood disorder, anxiety
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Co-morbidities: diabetes, developmental, social and educational problems
2. Physical Examination
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Screen for mood and bipolar disorders.
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Identify any signs of self-harm, neglect and abuse. If identified, immediate emergency services are required.
Signs of self-harm: unexplained injuries, making sure areas of the body are hidden
Signs of neglect: dirty skin, offensive body odor, unwashed, uncombed hair, undersized, oversized or unclean clothing, clothing inappropriate for the weather, frequent lack of supervision
Signs of abuse: unexplained changes in behaviour or personality, becoming withdrawn, seeming anxious, becoming uncharacteristically anxious, lacking social skills with peers, poor bond of relationship with parent or carer, knowledge of adult issues inappropriate for their age
3. Management
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Offer age-appropriate information on nature, management, and the course of depression.
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Discuss the range of effective interventions with the patient and caregiver, if appropriate, and, together, select a therapeutic intervention.
Patient Handouts
General Management
Conduct a risk profile for the risks of depression when a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience
Provide age-appropriate structured patient education (nature, course of treatment and likely side effect of medication, if applicable) and any of the following therapeutic interventions*:
Offer support and the opportunity to talk over the event. Provide active listening and conversational tone for acute sadness and distress (situational dysphoria)
Offer advice on the benefits of regular exercise and encouraged to participate in a structured supervised exercise programme of 3 sessions per week of moderate duration (45 min to 1 hour) for 10-12 weeks
Offer sleep hygiene education
Offer anxiety management
Offer nutrition advice and the benefits of a balanced diet
Consider ongoing social and environmental factors if dysphoria becomes more persistent to provide support where necessary
Always make contact with children and young people with depression who do not attend follow-up appointments
Recurrent Depression and Relapse Prevention
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Specific follow-up psychological therapy sessions to reduce the likelihood of, or at least detect, a recurrence of depression should be considered for children and young people who are at a high risk of relapse
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Recognize illness features, early warning signs, and subthreshold disorders
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Self-management techniques may help individuals to avoid and/or cope with trigger factors
Psychological Intervention for Mild Depression—5-18 years old
Provide watchful waiting followed by further assessment within 2 weeks. If depression continues after 2 weeks, and without signs of significant comorbid problems or active suicidal ideas or plans, select one of the following psychological interventions (adapted to developmental level as needed)*:
Consider digital cognitive behavioural therapy (CBT)
Consider group CBT
Consider group non-directive supportive therapy (NDST)
Consider group interpersonal psychotherapy (IPT)
If these options do not meet the child's clinical needs or are unsuitable for their circumstances, consider one of the following options:
Consider attachment-based family therapy
Consider individual CBT
Do not offer antidepressant medication as initial treatment
If patient has not responded to psychological therapy after 2-3 months, refer for review by a CAMHS team. Follow recommendations for moderate to severe depression if depressive symptoms continue after 2-3 months of psychological therapy
*Discuss the choice of psychological therapies (including the limited evidence for 5– to 11-year olds).
Psychological Intervention for Moderate to Severe Depression—5-11 years old
Provide a referral for patients to be reviewed by a CAMHS team and select one of the following psychological interventions (adapted to developmental level as needed)*:
Offer family-based IPT
Offer family therapy (family-focused treatment for childhood depression and systems integrative family therapy)
Offer psychodynamic psychotherapy
Offer individual CBT
Do not offer electroconvulsive Therapy (ECT)
*Discuss the choice of psychological therapies (including the limited evidence for 5– to 11-year olds).
Psychological Intervention for Moderate to Severe Depression—12-18 years old
Provide a referral for patients to be reviewed by a CAMHS team and select one of the following psychological interventions (adapted to developmental level as needed):
Consider individual CBT for at least 3months
If this option does not meet the child's clinical needs or is unsuitable for their circumstances, consider one of the following options:
Consider interpersonal psychotherapy for adolescents (IPT-A)
Consider family therapy (attachment-based or systemic)
Consider brief psychosocial intervention
Consider psychodynamic psychotherapy
Consider multimodal care if patient is unresponsive to a specific psychological therapy after 4-6 sessions:
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Combined pharmacological (fluoxetine) and psychological therapyᶿ†
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If patient responds well to medication, it should be continued for at least 6 months following remission (no symptoms and full functioning for at least 8 weeks)
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Consider inpatient care for patients who present with a high risk of suicide, high risk of serious self-harm or high risk of self-neglect, and/or when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated
Consider electroconclusive therapy (ECT) for young people with very severe depression and either life-threatening symptoms (such as suicid-al behaviour) or intractable and severe symptoms that have not responded to other treatments
Do not offer antidepressants except in combination with a concurrent psychological therapy
ᶿClosely monitor any child or young person prescribed an antidepressant for the appearance of suicidal behaviour, self-harm or hostility.
†If fluoxetine is unsuccessful or is not tolerated because of side effects, consider sertraline or citalopram as second-line treatments. Paroxetine, venlafaxine, and tricyclic antidepressants should not be used.
Treating Psychotic Depression
Provide a referral for patients to be reviewed by a CAMHS team and the following psychological intervention:
Consider augmenting the current treatment plan with a second-generation antipsychotic medication‡
‡Closely monitor any child or young person prescribed a second-generation antipsychotic medication for side effects
Treating Depression Unresponsive to Combined Treatment
Conduct a review of diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family
Discuss alternative psychological therapies not been tried previously:
Consider individual CBT
Consider interpersonal therapy
Consider shorter-term family therapy (3 months' duration)
Consider systemic family therapy (15 fortnightly sessions)
Consider psychodynamic psychotherapy (30 weekly sessions)
Care Pathway for the management depression in children (5-11 years old)
Care Pathway for the management of mild depression in young people (12-18 years old)
4. Reevaluation and Discharge
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Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.
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Monitor for any emerging factors that may delay recovery.
5. Referrals and Collaboration
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Refer the patient to child and adolescent mental health services (CAMHS) for further evaluation at any time during their care if depression is identified, suspected or if they develop new or worsening physical or psychological symptoms.
Referral Considerations
Indications that management can remain at primary level:
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Exposure to a single undesirable event in the absence of other risk factors for depression
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Exposure to a recent undesirable life event in the presence of 2 or more other risk factors with no evidence of depression and/or self-harm
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Exposure to a recent undesirable life event, where 1 or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child or young person
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Mild depression without comorbidity
Indications to refer to mental healthcare professional:
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Depression with two or more other risk factors for depression
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Depression where one or more family members (parents or children) have multiple-risk histories for depression
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Mild depression in those who have not responded to interventions in tier primary care after 2–3 months
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Moderate or severe depression (including psychotic depression)
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Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression
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Unexplained self-neglect of at least 1 month's duration that could be harmful to their physical health
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Active suicidal ideas or plans
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Referral requested by a young person or their parents or carers
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High recurrent risk of acts of self-harm or suicide
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Significant ongoing self-neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health)
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Requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3