We’re committed to making a real difference in the mental health of children and teens.
Weekly family therapy sessions are helping 5-year-old DaShawn Smither cope with a behavioral disorder he’s had since toddlerhood. His mother, Jennie
Smither, is one of about 60 parents testing a new Web-based tool designed to track how their therapy is progressing.
With most medical conditions, you can
objectively verify whether treatment
is having the desired effect. An X-ray
testifies as to whether the broken bone
is knitting together; a blood test proves
the infection is gone.
But there’s no lab test for mental
health. Determining whether treatment
for mental illness is working has
typically been based on the subjective
impressions of the person providing
The lack of objective evidence about
the effectiveness of treatment has
important implications, says Dr. Matthew Speltz, a psychologist and researcher
at Seattle Children’s. How do you know
when to change or stop treatment if
you don’t have a reliable way to tell
whether it’s working? How do you
know it will be worthwhile to stick with
it, even when it’s difficult or expensive
to do so?
Drs. Matt Speltz and Freda Liu are developing a Web-based tool to help determine whether or not
mental health treatment is working for a particular patient.
Speltz and Drs. Freda Liu and Nathaniel
Jungbluth are collaborating with
Dr. Corey Fagan and Jon Hauser from
the University of Washington to
develop a Web-based measurement
feedback system (MFS) for tracking
the effectiveness of mental health
treatment. The MFS was originally
developed by Fagan for adults. Speltz
and company are working with their
UW colleagues to tailor it for children,
teens and their families, and are testing
it with patients receiving outpatient
mental health services at Children’s.
Each week, a patient’s parents (and
potentially even his teachers) log on to
a secure Web page to answer questions
about feelings and behaviors related
to the child’s diagnosis and the goals
If the patient is old enough to read,
and to understand her diagnosis, she rates her own symptoms and progress
by responding to statements like,
“This week, I felt miserable or unhappy:
never, not true, true, sometimes, often.”
The MFS takes the reports of
patient, parents and teacher and
displays each person’s input on graphs
that show their view of the patient’s
progress over time.
There’s no lab test for mental illness.
“Since teachers typically aren’t
involved in our treatment process, they
are just seeing the results or lack of
results,” says Speltz. “Our hope is to
make it quick and easy for teachers
to weigh in at crucial points in the
treatment to provide their impressions
of the child’s progress.”
Jennie Smither is one of about
60 parents testing the new tool. Her
son DaShawn has been treated for a
behavioral disorder since he was a
toddler. DaShawn, now 5, and his
mom meet for weekly therapy with
Jungbluth. Since DaShawn is so young,
the therapy focuses on developing
Smither’s parenting skills so she can help him regulate his emotions.
Smither says she appreciates that
the tool is easy to use – she can fill
it out on her home computer, smart
phone or at a kiosk in the clinic waiting
area. “Responding to the questions
makes me think about what’s gone on
in the past week before the session, so
we can use the time in the session to
focus more easily on goals.”
Jungbluth says the MFS is a valuable
tool to shape the course of therapy
week to week. “For example, let’s say
today the plan was to talk about this
skill or address this specific problem
behavior that had been raised before.
We call up the survey results at the
start of session. Wow, mom is noticing
her overreactivity was a lot higher
this week. I ask about that, and sure
enough there’s an example that’s very
informative. Well, what went wrong
there? So we spend some time
“I’m a pretty visual person,” Smither
says. “I didn’t realize how much I liked using the tracking tool until we sat
down and looked at the data. In the
past, we just looked at the number
of outbursts, but with it charted out
on the graph, I can see DaShawn’s
While it’s not as clear-cut as a lab
test, the collaborative assessment that
MFS offers could be an important step
in the right direction.
A roadmap home
When police escorted Sarah Edwards’
son Marquee to Children’s Emergency
Department (ED) for the third time, she
knew it was no longer safe to have him
in her home.
Although he’s only 8 years old,
Marquee already has a long history of
frequent violent outbursts, many of
them aimed at his mother. Private
outpatient therapy proved no match
for his erratic, aggressive behavior.
When he tried to steal her car, it was
clear to Edwards that Marquee was
beyond her coping skills. “It’s really
hard when you’re afraid of your own
kid,” she acknowledges.
Luckily, this time there was a bed
available for Marquee in Children’s
Inpatient Psychiatric Unit (IPU).
On any given day, the waitlist for
Children’s IPU holds the names of 15
to 30 children or teens in crisis. When
there’s no bed available here, a child
may need to wait up to 10 days at
home or in an ED somewhere in
“These are kids who are an imminent
danger to themselves or others and
have exhausted the resources in their
community,” says Dr. Kelly Schloredt,
who co-leads the IPU’s clinical team.
Worsening the situation is the fact
that Children’s is one of only a few
hospitals in Washington, Alaska, Montana
and Idaho that consistently treats mentally ill kids under 12 and kids with
autism as well as a mental disorder.
Over the next two years, Children’s
will double the number of IPU beds,
from the current 20 to a total of 41.
Increasing capacity is important, says
Schloredt, but so is making sure that the
treatment kids are getting is effective.
Schloredt and her team have
developed treatment “roadmaps” called
clinical pathways to outline a plan for the
child’s entire hospitalization, based on
their diagnosis. So far, they’ve developed
pathways for depressive disorders and
disruptive behavior disorders – the two
conditions that account for the vast
majority of IPU patients.
1 in 5 kids experiences some form of mental illness.
“Clinical pathways enable us to talk
with the family immediately about what
we’ll be doing: here are the necessary
activities for you and your child,
here’s the evidence that these make
a difference, and we’ll work with you
to pass these on to your outpatient
team at home,” says Schloredt.
That clinical pathway was Marquee’s
road home. He’s now on effective
medications, and has gained enough
skills in regulating his emotions and
behavior to live with his mom again.
For her part, Edwards is grateful for
the nonjudgmental support of the IPU
staff, and their ability to identify and
connect her with resources in the
community. One of the most valuable
things, she says, is the parenting classes
she attended as part of Marquee’s
hospitalization. “It’s not intuitive to
parent a kid with mental health issues.”
“Bigger than your disease”
Dr. Carin Cunningham specializes in helping kids
and teens deal with the emotional and social
aspects of a serious illness like Crohn’s disease.
“My role is to help these kids maximize their
potential,” she says.
Starting kindergarten is an exciting
and stressful transition for any child.
For Ethan Roberts, the stress was
amplified by the fact that he was
diagnosed with Crohn’s disease just
before school began.
Crohn’s inflames the lining of
the gastrointestinal tract, causing
abdominal pain, fatigue, frequent
diarrhea, and severely reducing the
body’s ability to take in nutrients.
Treatment involves drastic changes
to the diet and time-consuming
intravenous infusions of medications
that cause more fatigue.
Although Ethan did OK at school,
once safely home he would lash out
at his parents in angry outbursts that
seemed uncharacteristic. “We took
Ethan to see two different psychiatrists,
but they were like deer in the
headlights,” says Ethan’s dad, Jeff
Roberts. “They just didn’t get Crohn’s.”
Enter Dr. Carin Cunningham, a
psychologist who specializes in treating
kids with gastrointestinal diseases like
Crohn’s. She knows the emotional and
psychological toll that dealing with an
intense, persistent illness can have on
kids – even when they don’t have an
underlying mental illness. That’s why Children’s is beginning to include
psychologists as part of clinical teams
for chronic conditions like Crohn’s, and
life-threatening diseases like cancer.
“Dr. Cunningham helped Ethan see that
his life is bigger than his disease.”
Ethan and his parents began seeing
Cunningham several times a month.
“We knew the minute we sat down
with her that she understood Crohn’s,”
Roberts says. “Her knowledge helped
lift the weight off our shoulders. She’s
able to treat the emotional and mental
side of it – for him, and us.”
Cunningham literally “wrote the
book” on this topic; she’s the author
of a comprehensive resource on
the biopsychosocial aspects of
gastrointestinal disorders in kids.
Jeff Roberts (pictured, right) says regular medication infusions keep his 8-year-old son Ethan’s Crohn’s
disease under control, but it’s the coping strategies Ethan learned from pediatric psychologist
Dr. Carin Cunningham that made it possible for Ethan to take back control of his life.
“It’s so hard to be a kid and go
through this,” says Cunningham.
“My goal is to help patients like Ethan
deal with their illness so that it has
the least impact on their development
as a person, and also to help parents
support their children. Most kids with
Crohn’s just want to be kids and live
their normal lives. My role is to help
them do just that.”
Having a pediatric psychologist
“embedded” in the care team means
that both physicians and families have
access to psychological resources right
in clinic. “Plus,” says Cunningham, “it
makes the transition easier and helps
side-step any stigma about ‘seeing a
psychologist’ when I’m just part of the
team, like the nutritionist or child life specialist.”
Cunningham helped Ethan understand
and control his body better, and find
healthy ways to express what he needs
to his parents.
For Roberts, the change is summed
up in one of the main lessons that
Cunningham taught his son, now 8
and in second grade. “She’s helped
Ethan see that his life is bigger than
Published in Connection magazine, September 2013