By Tara Bannow

The Bulletin

It’s not uncommon for physician assistant Sharon DeHart to get a child in her office who appears to have symptoms of attention-deficit hyperactivity disorder — not focusing at school, behavioral issues at home, lack of friends — but she isn’t sure about the diagnosis.

DeHart, whose rural Maupin clinic treats about 2,000 patients, doesn’t specialize in pediatrics, much less pediatric mental health, but she’s forced to see a lot of children at her job.

“Even though I’ve been practicing for a lot of years, I’ve been doing more adult medicine and not a lot of pediatric,” said DeHart, who manages the Deschutes Rim Clinic.

The clinic has been recruiting a physician who can treat kids for five years now, but it’s not easy to attract people to the town of about 400 people roughly two hours north of Bend. The clinic has a counselor, but he doesn’t see kids.

DeHart has taken to relying on advice from pediatric psychiatrists at Oregon Health & Science University, whom she frequently asks about the medications she’s prescribing kids and their diagnoses.

“I think they’re an outstanding resource, especially for those of us who don’t live in Portland and don’t have access to Doernbecher or Randall Children’s Hospital or OHSU,” she said.

OHSU’s pediatric psychiatrists spread their expertise across the state — which, like many others, lags with respect to the number of pediatric psychiatrists available — in a couple of ways. The specialists in 2014 launched a phone service, called Oregon Psychiatric Access Line about Kids, which providers can call to receive free consultations about difficult cases. This past summer, they also began providing video conference classes on the subject for providers through a temporary grant.

Providers in Central Oregon appear to be taking full advantage of those services, a trend some attribute to the severe lack of pediatric psychiatrists here. Between OPAL-K’s launch in May 2014 and June 2016, Deschutes County saw the fourth highest per capita use rate of OPAL-K, behind more rural counties such as Wheeler, Sherman and Clatsop.

Dr. Darin Vaughan, a pediatrician and director of pediatrics and school based health centers for Mosaic Medical, said OPAL-K is a regular resource for the community health center’s pediatric staff. He thinks that’s driven by the lack of mental health services for kids in Central Oregon, Vaughan said.

“I think we still suffer a real serious lack of child psychiatrists in the area who would certainly, if available, decrease our need to get on the phone and call a specialist for advice, because the specialists were on hand, say, down the hall or down the street to see those patients,” he said.

Pediatric psychiatrist shortage

The high use locally could also be due in part to a higher level of awareness of its existence here, Vaughan said. And once providers use the service, they tend to use it again, he said.

“There are not enough of these kinds of resources in a geographically strained area like we have here in Bend,” he said, “where not all the medical specialists we would love to have available for children are immediately in our reach.”

OPAL-K’s eight pediatric psychiatrists fielded slightly more than 1,000 calls between May 2014 and June 2016, according to a report from OHSU. More than 1,200 providers in Oregon have signed up to use the service.

Dr. Keith Cheng, OPAL-K’s medical director, estimates there are between 120 and 140 pediatric psychiatrists in Oregon, about half as many as is necessary to meet demand. That means primary care providers wind up treating more mental health problems.

“I do believe that the lack of outpatient or lower level of care is the reason we get more calls,” he said.

Far and away the three most common diagnoses among the patients OPAL-K providers discuss are ADHD, anxiety and depression.

In most cases, the primary care provider continues to provide care for the patient after receiving advice from OPAL-K. Some patients also see therapists or are referred to psychiatrists.

Only about four or five out of the roughly 1,000 patients whose providers used OPAL-K ended up in emergency rooms or other inpatient settings, according to OHSU. Cheng said the goal is to keep patients under the care of their primary care providers and avoid those acute settings when possible.

Central Oregon lacks inpatient psychiatric beds for kids, so many who need that level of care are forced to wait at the hospital for those beds to open up in Portland.

Trauma triggers symptoms

OPAL-K’s providers encourage callers to determine whether the child’s symptoms could stem from a history of trauma, such as domestic violence, drug and alcohol abuse among family members or bullying at school, Cheng said. He said it’s not uncommon for OPAL-K’s psychiatrists to determine children are being medicated for one condition, when their symptoms are actually the result of trauma.

“We want to help primary care clinicians understand that they need to be looking for trauma before they diagnose these other disorders,” Cheng said.

A wealth of research has accumulated over the years linking past traumatic events to the development of physical and mental health problems — things such as heart disease, diabetes, obesity and depression — down the road.

“People think of trauma, ‘Oh, motor vehicle accident,’” DeHart said. “No, trauma can be a divorce in the family. Trauma can be some abuse from sibling to sibling or an adult to a child within the family unit.”

Working with OHSU’s experts through its videoconferencing classes has brought trauma to the forefront when DeHart works with patients. It’s caused her to focus her line of questioning, adding more about kids’ home lives. (She just recently learned about OPAL-K, and said she plans to use that, too.)

Now that the research is so clear on the effects of early trauma, Vaughan said Mosaic’s providers not only address the issue with patients, but they work to help prevent traumatic situations from unfolding. That could mean identifying postpartum depression, providing housing or ensuring families have enough food, he said.

“There are some real, concrete ways that our community and our government can provide support to limit the need that many children will develop for mental health services by providing effective, meaningful strategies to reduce toxic stress on children,” he said.

— Reporter: 541-383-0304,