So, why don't we go ahead and take our first question. It really has to do with handoffs, and so it basically asks, for those who only treat pediatric patients, when would you suggest handing off someone to an adult provider and how do you identify an appropriate adult provider, particularly since these disorders cut across the lifespan? Absolutely. That's a great question. So, you know, everyone's scope of practice is obviously different, and so I know there are some people whose licenses only allow them to treat up to a certain age. I always recommend trying to start that handoff process, again, as early as possible. So, if you're working with someone, you know, mid-teens, like 14 to 16, getting them and family involved in identifying an appropriate adult provider. So, that can sometimes look like, you know, calling around different resources, getting the family and hopefully getting the patient involved in calling around for different adult practices, you know, identifying providers within your community that have special interest or training in working with this population can go a long way to create a community-based network so that pediatric providers have the ability to do this kind of one handoff to a provider that they know. I also will often encourage families and patients to interview adult providers, especially if they've got a close relationship with their pediatric team. It can be pretty scary to move out of the pediatric world and start to look at adult care. And so, having the opportunity for patients and families to go in while they're still in the pediatric lens and just have open conversations with their adult provider, getting to know them to ensure that that's a space they feel comfortable receiving care. So, I think, as always, one of the most frustrating answers in all healthcare is it depends, but I do think starting that process early and including the family in that process goes a long way in building your community referral network of providers you feel comfortable with. And that's where, again, the NADD is a really excellent resource. They have some listings of providers that they work with that could be a good place to start. Great. Thank you. And I guess related to that question, is there any specific advice that you give to parents as their child is approaching age 18 or, in some cases, 25 around health insurance considerations they need to be thinking of for those who are going to need chronic care for their psychiatric illnesses and their IDDM diagnoses into adulthood? Absolutely. So, to make sure I understand that. So, question correctly. So, kind of conversations with families when it comes to things around insurance coverage, transitioning out of the pediatric system and into adulthood. Is that right? Yeah, exactly. So, I definitely encourage families to think about insurance coverage as early as possible because we know the insurance system can be a tricky one to navigate even in the best of situations. And so, getting individuals to start thinking about how long can your child stay on your insurance? What do your benefits look like when they do transition off of it? Do you have access to things like Medicaid or Medicare based on their diagnoses? Some young people may qualify for Medicare. And so, exploring that resource can go a long way in order to and continue to have access to care for these issues. So, that's one piece. And then, encouraging families to have the space to express their frustration. This is, again, where I think case management can be really powerful for this population because it's a frustrating situation for parents, particularly if they don't have guardianship of an 18-year-old, to recognize that once that child turns 18, we may not be able to even talk with this parent. And so, getting releases signed as early as possible and really opening the conversation about guardianship sooner rather than later because it can be a fraught legal process. There can be some complicated emotions about guardianship, but there are some individuals where that's really their best option. And guardianship doesn't have to be permanent. There are some young people I've worked with where we've looked at guardianship just for a transition period and then helping that individual grow their independence has allowed them to transition out of the guardianship model into being their own independent entity. I think that guardianship piece of advice is so helpful, particularly since for all the reasons you just highlighted around turning 18 and the medical establishment automatically throwing up some rules around what can be shared with other people. So, thank you for mentioning that. And I think it dovetails nicely with a big initiative we're doing here at SMI Advisor around psychiatric advanced directives, which we'll be telling all of you more about in the coming months. I also wanted to ask you about, at SMI Advisor, we're very interested in the idea of the interprofessional care team. And we certainly embrace that within our clinical expert team, having psychiatrists and psychologists and nurse practitioners and peer specialists and social workers. If you were designing the ideal interprofessional care team for those with intellectual and developmental disabilities and comorbid SMI, who would you put on that team? What would that team look like? That's a great question. So, in all things, we want to have a patient-centered care team, so patient and family, including not only primary care, but the medical specialists. And like I mentioned with the adjunctive therapies, you're remembering that oftentimes these are individuals who've had long-term relationships with things like speech-language providers, with occupational and physical therapists. So, making sure that those care providers are part of the team, because they can provide a unique perspective on not only the treatment they're providing, but also things like the individual's stress capacity, what their relationships look like, including educational systems on that care team. I want to be involved with the school, particularly for some of our individuals with intellectual disabilities, they're going to be in school longer than some of our other young people may. And so, talking with the school and the educational supports they have, like I mentioned, their medical specialties, their home life, I want those people on the team, if they're living in a group home, and I want to know, I used to work in a setting where I had the opportunity to work with the nurses in a group home and it was wonderful to be able to speak with them as the prescriber, because they had a really amazing insight into what this person's daily life looked like. So, for me, having all those domains covered, home, whether it's education or vocation, whether these people are in school or they're working, having as much contact with the different domains of their life, as well as their mental health team, therapy, psychiatry, all their different medical providers, it's a large team we're asking for here, but for these individuals, the hope is to create a network and a community so that we don't lose them in the cracks, particularly in this transition time. We have a question from one of our nurse practitioner viewers who writes in, how can you comprehensively assess psychiatric symptoms and side effects in patients with SMI slash IDD who are nonverbal or have limited communication abilities? I guess that goes for all the measurement-based care that you had mentioned previously around using rating scales, such as the PHQ-9 and those kinds of things. How reliable are those tools in folks who have both SMI and IDD? Absolutely. I think that's one of the big challenges of the rating scales that we use is that in a lot of the clinical work we do in psychiatry really relies on the patient being able to tell us about their internal world. And for individuals who are nonverbal, we may not be able to get that information. This is where including the family and the caregiver goes a long way that provides at least some evidence around things like irritability and behavior changes. They may help us start to monitor, aha, we started this medication, this individual hadn't been engaging in headbanging before, and now they're engaging in headbanging behavior. Well, that should really raise our question and concern, is our treatment helping? What's it inducing if now the behavior is changing for the worse? And that's where, again, to go back to the NADD, their DMID-2, that diagnostic manual, that companion to the DSM is a really phenomenal resource when it comes to sort of teasing apart the way the IDD and the SMI may be presenting and may be running in tandem to one another. So that's a resource I would definitely encourage people to take a look at if you're working with this population. Excellent. There's sort of a related question that asks, you know, coordinated specialty care has been used as a treatment for those with clinical high risk and first episode psychosis. Are individuals with intellectual and developmental disabilities able to participate them in a meaningful way? I think, you know, that's where it's going to depend on the nature of the disability. Again, this is a heterogeneous group, and so I think there are some individuals who would benefit incredibly from this type of coordinated care, and there are other individuals who it may not be sufficient. They may need more intensive support, such as residential care, and other individuals who may be capable of functioning in less intensive settings. So I think there's definitely value to looking at that model, especially when we're thinking about the vulnerability of this population. I think, again, this is one of those unfortunate it depends sort of situation. Each individual is going to have different needs, but I think the, you know, kind of pre-prodromal treatment style of these first episode psychosis programs can be great for the transition age because it helps us start to identify treatment needs in a more preemptive way. Great. I think we'll take one last question here, and it says, as these individuals transition into adulthood, another transition question, what are your recommendations around frequency of psychiatric medication management if they have been fairly stable as a preteen, but they're encountering psychological or metabolic changes or psychosocial stressors? So I guess during that transition time is a period of vulnerability. Do we think differently about follow-up even for someone who's doing well? Yeah, I think there's some value to increasing our follow-up, even if that's purely a kind of eyes-on moment, but it can create a really powerful therapeutic space with the client as well, even if we're not changing medication, to be able to engage them in conversations around, you know, what's working about that transition, what isn't. You know, I take our role as coordinators in the healthcare system. You know, I think it's really hard when we're in the prescribing role. Oftentimes, we're really just in the prescribing role, but I think taking the opportunity, even if someone is psychiatrically stable, you know, having more frequent contact, A, allows us to catch any signs of decompensation as quickly as possible, but also strengthens our alliance with this individual and helps us ensure that they're getting the support that they need. So that's my practice style, at least, is during these vulnerable times, I definitely increase the frequency of my visits, but I also appreciate, you know, when it comes to resources and availability, that may not always be an option, so again, not to be a broken record, but again, I think this is where case management can become a really wonderful resource for this population to kind of help us better monitor, you know, when an individual may need more support, whether that's biologic, psychologic, or social support.

intellectual and developmental disabilities

psychiatric illnesses

handoff to adult providers

National Association for Dually Diagnosed

coordinated specialty care