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Multidisciplinary intervention for failure to thrive--casebook.

Article Excerpt
They were often inconsolable. Aidan's shrill cries could be heard up and down the hallway on days he came in for a weight check.

Audrey and Jonas were newlyweds happily expecting their first child. Audrey was working toward her master's degree, while Jonas attended a local community college and worked full time as a technician. They presented for an acute visit late in Audrey's third trimester with concerns about Jonas' increasing anxiety and difficulty sleeping. He initially requested medication to help him sleep and calm him. He was anxious but articulate at the initial interview, and was very concerned about the side effects of the medication. Dr. Brown initiated a referral to the practice's integrated behavioral health services and prescribed a tricyclic antidepressant. Jonas and Audrey agreed to follow up in 2 weeks.

Two weeks later, just days before the scheduled follow-up visit, Jonas called in crisis from the parking lot of his workplace. "I think I'm going to kill my boss," he panicked, asking for guidance about what to do next. He had not reported any previous incidents at work, nor difficulties with anger management, although he did describe frustrating workplace dynamics and interpersonal relationships. He would later explain that he felt devalued there, disrespected, and constrained by new leadership, new rules, and increasingly unreasonable demands for productivity. Dr. Brown spoke with him and supported him for calling in a frightening moment. She encouraged him not to reenter the building at that time. She sought consultation with her supervising attending and the behavioral health director. They recommended that Jonas begin a trial of a typical antipsychotic for sleep and follow-up as soon as possible with a mental health provider. Although Dr. Brown had already made the referral, the transition from the previous year's behavioral health providers to the new providers was in process. Jonas was eager to follow up and waited to be scheduled. The team discussed the pros and cons of referral to the psychiatric emergency department, ultimately deciding that he could follow up in primary care because he lacked a clear plan or intent to harm himself or someone else, and preferred to be evaluated at his primary care practice. Prior to this presentation, he had been seen for a few visits by the primary care team, but already he was connected to the practice and wanted to make it his medical home. He trusted Dr. Brown, and opted to wait to be seen by the on-site behavioral health services rather than divide his care among multiple departments. A few days later, he arrived at the check-in window and demanded to be seen immediately.

On Jonas' arrival at the clinic, Dr. Brown again sought consultation from the mental health professionals integrated in the clinic. She interrupted a meeting between a new medical family therapy intern, Dr. Rosenberg, and her supervisor, Dr. Gawinski. Dr. Brown discussed Jonas' presentation earlier in the week, requesting that the mental health professionals see him immediately given that he was waiting in an exam room. Dr. Rosenberg and Dr. Gawinski agreed. They saw that Jonas was disheveled, his head hanging down, and his legs shaking. A young woman sat to his left, worried, tearful, and pregnant, with her arm around him, trying to reassure him.

Jonas told his story. He was a fraternal twin born to a mother with mental disability and a drug-abusing father. Because his parents were unable to care for him, Jonas and his brother were raised by his strict, religious, extended family. His twin brother died of meningitis when they were school age, and his experience was largely that of an only child. Jonas had a prior history of anxiety and emotional dysregulation, and he was briefly treated...

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