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With increased attention paid to the high prevalence of unaddressed mental health problems among our youth, there is a growing demand for increased capacity of mental health care in pediatric primary care (PPC) practices . There are two good reasons why the PPC setting can make a large impact in detecting and managing child and adolescent mental health problems. First, almost all of children and adolescents across economic and ethnic populations use PPC services. This provides a unique opportunity to apply universal screening, assessment, and preventive intervention to the large majority of the population. [1] Second, pediatricians generally have a long-term relationship with the families they serve. This relationship provides the basis for continued mental health surveillance and monitoring from early childhood to adolescence. [2] Despite these assets, however, evidence indicates that systematic screening and assessment of mental health problems is not occurring universally. In fact, even in research studies evaluating screening and assessment protocols, rates of adherence average about 50%. [3] When it does occur, practices often rely on suboptimal procedures that do not adhere to best practice, evidence-based assessment strategies. [3] There are a number of reasons why we are seeing these shortcomings, which have to do with both systemic and practice-level barriers. Pediatricians feel that they are under-trained to diagnose and treat mental health problems. When they do diagnose mental health problems, pediatricians struggle to find appropriate resources for making referrals. Collaboration between pediatricians and mental health providers is inadequate. Pediatricians often do not know whether their patients successfully made it to a mental health appointment and are not informed of ongoing progress. This partly has to do with pediatricians’ failure to ask for this information, as well as mental health providers’ hesitation to provide mental health information back to pediatricians. Indeed, despite that HIPPA permits information to feed back to a referring physician, in support of continuity of care, there are various state laws that can supersede this. Another barrier includes lack of available time and insufficient staffing in the PPC to conduct universal screening and assessment. When standardized screening is applied, pediatricians often struggle to score and interpret results. Finally, there is a lack of knowledge of existing coding mechanisms that can lead to reimbursement for mental health services with primary care.

So, what is needed to better integrate mental health with pediatric primary care? An effective protocol needs to be feasible and reimbursable, and should address these outstanding barriers. We need further research to determine how best to foster the pediatrician – mental health provider relationship in order to establish co-management of child mental health. Given PPC’s reach and long-term relationship with families, there is real value in using primary care as a place to document and track the progress of mental health problems. Often, patients receiving outside mental health services see a number of different mental health providers over their childhood and adolescence and keeping this information together is a challenge and can lead to fragmented care. Finally, we need an adaptable screening and assessment protocol that will fit into the PPC workflow – which may vary among practices.

What has been your experience with mental health in pediatric primary care? What barriers have you observed? If you are a practicing child mental health professional, what could be done to improve your relationship with pediatric providers towards accomplishing co-management of mental health problems? Please comment here or on our social media pages (Facebook, Twitter, LinkedIn).

References:

  1. Connor DF, McLaughlin TJ, Jeffers-Terry M, et al. Targeted child psychiatric services: A new model of pediatric primary clinician – Child psychiatry collaborative care. Clinical Pediatrics. 2006;45(5):423-434. 2.
  2. Burka SD, Van Cleve SN, Shafer S, Barkin JL. Integration of pediatric mental health care: an evidence-based workshop for primary care providers. J Pediatr Health Care. Jan-Feb 2014;28(1):23-34. 3.
  3. Wissow LS, Brown J, Fothergill KE, et al. Universal mental health screening in pediatric primary care: a systematic review. Journal of the American Academy of Child and Adolescent Psychiatry. Nov 2013;52(11):1134-1147 e1123.

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