PAL Monthly Newsletter | August 2019
From your PAL Psychiatrist
Psychiatric Assessments - by Dr. Josh Stein

Psychiatric assessments for children continue to have both extensive wait times and geographic disparities. In the state of Minnesota the only county according to the American Academy of Child Adolescent Psychiatry (AACAP) to have an adequate child psychiatrist to patient ratio is Olmstead, due to presence of the Mayo Clinic. Given these issues, the burden to initiate care often falls on the pediatrician or family practitioner regardless of the complexity of the situation. The goal of PAL is to provide support for these providers with immediate phone consultations at the moment they are needed. 

The most common but also most difficult diagnostic patient is the irritable young child. The differential is extensive and includes learning disorders, social concerns, adverse childhood events, mental illness and medical considerations including absence seizures. A common question from primary care is, "can medications be used for treatment even if the differential outside of mental health cannot be exhausted?" 

There is no simple approach, however the outline below is beneficial:
  1. Do these concerns happen in all environments or just one? (School vs home; mother’s vs. father’s home; summer camp and home). Although the diagnostic criteria for ADHD requires two environments, this can be a helpful clarifying questions for all diagnoses.
  2. Is there a “Big T” or “Many little Ts?” Trauma comes in all sizes but the concern is the impact on the child. Stress hormones can be equally elevated at baseline in children who have had numerous small impactful trauma’s such as moves or bullying. Determining if trauma is present is an important first step.
  3. Is there a learning or developmental disability? While psychological testing is an important tool to clarify diagnosis, especially in children struggling with agitation in school, it is not readily available. Treatment can often not wait the three to six months for testing. Clarify reading level and feedback parents have heard from teachers.
  4. Does the child remind the parent of anyone? Often there is a similar pattern to parents that can be clarifying diagnostically.
After clarification of the details above, there is often treatment modalities that are non-pharmacologic that are primary. This is includes recommendation for an IEP, an occupational therapy eval, in home skills, family/individual therapy, tutors, glasses, social skills groups etc. These are primary, but medication initiation, especially those that palliate severe agitation symptoms can be an effective adjunct treatment. 

The goal is often to decrease agitation to the point that the above non-pharmacologic options can be started effectively rather than lead to further escalations. Hydroxyzine, clonidine and guanfacine often demonstrate benefit in the short term setting while the above treatments are initiated. 

In addition to psychiatric consult services with PAL, there is also a triage therapist available to assist with non-medical questions, referrals and concerns. They are available to help find services throughout the state of MN.

You can contact PAL by calling 855-431-6468,, or scheduling online!

Pediatric Psychiatric Med Management
& Trauma Care Trainings
The PAL team and a Nationally Certified Trauma Therapist provide FREE and CME-approved trainings for primary care providers and healthcare professionals that are focused on pediatric mental health assessment and treatment. 

PAL will present from 8am-12pm:
  • Overview of the Psychiatric Consultation Service and the importance of early identification of mental illness
  • Psychopharmacology (eg. Stimulants, SSRI's, SGA's, and Mood Stabilizers)
  • Metabolic Monitoring
  • Pharmacogenomics testing
  • Community Resources,, and collaborative care models

Trauma Care therapist and trainer will present from 1-5pm:
  • Psychotherapeutic modalities with a particular focus on evidence-based practices
  • Appropriate screening, referral and treatment of traumatic stress in children and youth
  • Ensuring adequate assessment and the appropriate diagnosis and treatment of ADHD in children and youth (e.g., differential diagnosis, alternatives to pharmaceutical treatments, etc.)
PAL Psychiatrists
Adam Klapperich, DO

Dr. Klapperich is a board certified child/adolescent and adult psychiatrist. He joined PrairieCare Medical Group in Edina in 2012. He has since worked in inpatient, partial hospitalization, and outpatient settings at PrairieCare. Dr. Klapperich attended the University of South Dakota before graduating from the Kirksville College of Osteopathic Medicine. He completed psychiatric residency and child and adolescent psychiatric fellowship training at the University of Minnesota. Dr. Klapperich works with children and adolescents in the newly opened Maplewood location.
Joshua Stein, MD

Dr. Stein is the clinical director and an attending clinician at the Brooklyn Park Partial Hospital Program (PHP) and operates a clinic out of the Brooklyn Park Medical Office Building. The clinic is used as a bridge for patient's leaving PHP until they can see their outpatient provider. The focus for care is not just on immediate obstacles and gains, but improving long term trajectory as well. As the president of the Minnesota Society for Child Adolescent Psychiatry he focuses on local and national advocacy for children's mental health with a goal to increase access to quality care.

Fast-Tracker is Minnesota's free, easy-to-use tool designed to connect people with resources and services. 

They connect individuals, families, mental health and substance use disorder providers, physicians, care coordinators, and others with a real-time, searchable directory of mental health and substance use disorder resources and their availability within Minnesota.

For more information, call Fast-Tracker 651-426-6347 or visit their website:
Mental Health Resources & Treatment Protocols for Primary Care

Child and adolescent psychiatric treatment protocols are available on our website under the Training & Education tab. The treatment protocols are specifically for medical providers, and the fact sheets are intended for caregivers/families. 

Please click here to view the Child and Adolescent Treatment Protocol Guides!