Dr. Cori Cross (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Cori Cross. Today, we'll be exploring how a specialty psychiatric day treatment program at Children's Health is providing intensive structured care while still giving kids the support and compassion they need to thrive. For this discussion, we have Dr. Laura Stone with us. She is the Associate Professor of Psychiatry at UT Southwestern and the Medical Director of the Psychiatry Day Treatment Program at Children's Health. Dr. Stone, thank you for joining us today.

Dr. Laura Stone: Thank you so much for having me.

Host: So, let's jump right in. This is a super complex issue, but set the stage for us a little in understanding the behavioral health challenges for youth and their families when they come through the ER. It's obviously not the easiest place to handle behavioral health issues in general. And inpatient for adolescents and teens is quite difficult. So, explain to us sort of the complicated reality of behavioral health for these youth and their families.

Dr. Laura Stone: Yes. Managing psychiatric disorders in the emergency department is certainly a challenge. One is looking at what the level of care of treatment is that the patient requires. And sometimes they're needing inpatient psychiatric treatment, which would require transporting and getting them to an available psychiatric bed that's appropriate for them. This is obviously a complication for the emergency department. This is utilizing the resources, and it's also delaying mental health treatment for that patient.

Host: Right. Because ERs really just aren't set up for that. And what listeners might not realize is that even though there might be so many beds in a hospital, different beds are utilized usually for different purposes. And so, you can't just put a patient who has a psychiatric need or behavioral problem on any floor. So, it can be almost like playing Tetris to try to fit everybody in where they belong. So, give us an idea of how then the psychiatry day treatment program addresses these problems. Because obviously, it's a day treatment program. So, they're not inpatient staying there. But how do you do the intake so that they're not going through the emergency department?

Dr. Laura Stone: So, we schedule assessments with patients and their families typically a parent, but I'll be using the term guardian as much as I can just because we know that family structures can vary. So, they come in for an assessment. If the patient is able to be safe in a home environment where they're staying at home overnight and parents are supervising and then can come in to our program during the day, typically during what would be normal school hours, then we do our very best to maintain them in the day treatment program without having them go through hospitalization first.

Host: Now, is it their doctors or school referrals or are they coming from an emergency department that says, "Okay, you don't need to be admitted today, but I want you to follow up here." How do patients get directed towards you?

Dr. Laura Stone: All of the above. You found several of the resources that we get referrals from. We have connections with some community providers with inpatient psychiatric units. We have our psychiatry and psychology providers here at Children's as well. And so, we get referrals from everywhere, all over DFW and sometimes even further out.

Host: And how big is your unit, is the program?

Dr. Laura Stone: So, we have two cohorts. One is a child cohort from ages six through twelve. And then, we have an adolescent cohort that is 12 through 17. So, a 12-year-old could go into either group, depending on their level of maturity. So, we can have about seven patients in each cohort, so a total of 14 at a time. So, we're a very small program and, hopefully, one day we'll be able to expand or have additional locations to be able to see more patients.

Host: I would imagine that the need is there, so that would be phenomenal.

Dr. Laura Stone: Exactly. And we're a specialized program as well. So whenever people are being referred to our program at day treatment, sometimes there's a specific reason such as they have medical conditions that may not be able to be addressed within other programs or their providers are all within Children's and we're able to collaborate with them to provide the best care possible.

Host: That makes sense. And just for the issues that you do treat there, I'm assuming it's depression, anxiety, are there also like eating disorders? What is it that is within your breadth of work?

Dr. Laura Stone: We do have a lot of patients with depression and anxiety. We can treat patients that have eating disorders as long as that eating disorder is stable at the time and is not their primary diagnosis. Children's Health does have an eating disorder program with various levels of care and they're able to provide treatment for the patients that have a primary eating disorder.

Host: That makes sense. And then, could you tell me a little bit? I mean, about in my experience, and I am a pediatrician, when you have children or teens who need to go inpatient, I mean, sometimes it's absolutely necessary and unavoidable. But sometimes it's just the only solution that we have. And being in a hospital as an inpatient is already stressful and can be anxiety and depression-inducing anyway. So, what are you seeing in terms of results and how this program is received by patients and their families?

Dr. Laura Stone: We hear a lot of positive reviews. I may be biased, but that is true. We get a lot of praise and gratitude from our families and patients, which is really nice to see. I think part of that is that we're more of an outpatient program. We're not an inpatient hospital where things may feel kind of scary or patients are really very separated from their families and their home. So when they're in day treatment, they're still able to see their families and go home. And we're in an office-type setting rather than a hospital. And so, people tend to feel more comfortable, and then that leads to improvements in outcomes as well.

Host: That makes sense. And then, talk a little bit about that. So, you are in an office-based setting. What is a child or a teen's day look like when they come to the program?

Dr. Laura Stone: Sure. So, our day starts at 8:30 and we do a check-in group in the morning with the patient and their guardian. And that allows us to get information from how things went overnight. At that point, the guardian leaves, the patient attends groups. They have lunch, they meet with the psychiatrist. They may have individual therapy or family therapy. And the day ends at about 4:00. We end the day with a checkout group, so that allows the guardian to know what their day was like while they were in the program. And so, we have that constant communication between the providers in the program and the guardians. That way, everyone knows what's going on, and it really improves the communication and understanding of exactly what we're trying to help.

Host: The day sounds really well-packed, but also very well-thought out. Now, this program serves Dallas and Fort Worth area. What would you say to other hospitals or healthcare systems looking to implement something similar and considering this type of model? What advice would you give them?

Dr. Laura Stone: First, I would say that they need a multidisciplinary team with lots of different specialized individuals. So, we have different types of therapists, including the individual and family therapist, as well as therapists that do experiential groups such as recreation therapy, music therapy. We also have nurses, physicians, specifically child and adolescent psychiatrists. And teachers that provide the school services that are needed. So, all of these team members are really critical to create a setting where the patient is getting all of their needs met. We also have the behavioral aspect of our program. So, that's a whole other focus that, for us, works really well.

And the other part of our program is the behavioral aspect, and it's very important that all of the different staff members in a program are united and able to be consistent in the way that they work with patients and handle any challenges that may come up.

Host: Yeah. No, I think you make a very good point that it is a very complex situation. You need to have a lot of different specialties involved, but that we're dealing with children. So, it's the schooling as well as the behavioral health as well as the sort of making sure that they have a little bit of fun throughout their day. It's a complicated situation that really needs to be well-thought out on the part of the developer of any type of program for this.

Dr. Laura Stone: Exactly. A lot of planning goes into it, and day treatment has been around for decades. And there have been many changes over the years to make it what it is today.

Host: It sounds like a wonderful resource for children and teens in the Dallas-Fort Worth area. I am sure that you often are booked to capacity with having 14-patient cohort max. Before we wrap up, is there anything else you'd like to add for our listeners?

Dr. Laura Stone: I'd like to highlight some data and results that we've been collecting. So, we use standardized scales to assess our patient's level of symptom severity, and guide treatment decisions as well as to collect the outcome data. So, patients that are 11 years old or older complete self-report questionnaires on admission and then weekly thereafter, and guardians complete rating scales at admission and discharge.

Over the course of day treatment, we see an overall improvement in symptoms and functioning in all areas. And then, when we look specifically at data since January 2024, so over a year and a half worth of data, we have a reported decrease of 40% in depressive symptoms from patient report, and 55% decrease from the guardian's report for depression, and then for anxiety from the patient report is a 33% decrease in anxiety symptoms and the guardians report a 24% decrease. And with day treatment only being three or four weeks long, these are pretty impressive results and one of the most important things after finishing the program is that they do have follow up in the community with the therapist and psychiatrist. And the family is maintaining what they learned in the program to maintain those gains.

Host: Yeah, I mean, it really sounds like you've developed something that is the best of like all possible worlds, if you have to go through this, almost like the gold standard, because you're not pulling the kids away from their families, you're still addressing their school needs, which often doesn't get met when they're in an inpatient program or doesn't get met sufficiently. You are addressing the growth that has to happen within the family, including with their guardians, how they're experiencing everything. And then, it seems like you're able to, because it's a day treatment program where they're coming consistently, almost sort of jumpstart the system where you can do some intensive work upfront. It seems like the results you're getting show that the work you're doing is effective and you're able to get that like double down right in the beginning so that you can lay a foundation and set that up so that when they are then transferred to truly being outpatient, and going on a less frequent basis than daily, and following up that they're able to maintain that and continue that growth.

It sounds like, at least to me, that you've set up a really well-thought out plan for this and for the progression of what needs to happen, because a lot of times it seems to me again that we deal with the acute problem in behavioral issues or psych issues, but we fail the patients often when we don't give them the follow-up they need and we don't give the family the support they need. So, it sounds like you're addressing all of these situations.

Dr. Laura Stone: Well, thank you. That is our goal. You've said it very nicely that we're working with the patient and their family and really they're community almost, because we're talking about school, we're talking about activities they do. We're involving their providers if they've already got established treatment and really working to set them up for success by having everyone working towards the same goals.

Host: That's wonderful. Well, thank you, Dr. Stone, for taking the time to speak with us today and informing us on such a great program that's available in the Dallas-Fort Worth area. If you would like more information about the psychiatry day treatment program, please visit childrens.com. Thank you so much for your time with us today and for our audience for listening to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childre.com. And if you found this podcast helpful, please rate, review and share this episode. And please follow Children's Health on your social channels. Thank you.